Music Therapy Today, Vol. 6, No. 4 (part 3)

Music Therapy Today, Vol. VI, Issue 4, (November 2005) a publication from MusicTherapyWorld.net

CHAPTER 45

Musical features in music therapy improvisations of clients with mental retardation

Riikkilä, Kari M.A., music therapist University of Jyväskylä, Department of Music PL 35 (A313), 40014 University of Jyväskylä, Finland katariik@cc.jyu.fi

Abstract Improvisation has been used in clinical music therapy with a variety of conditions and can also be used in the education of music therapists as Erkkilä (2000) has reported. Analyzing improvisations is a time-consuming procedure and is therefore mainly applied in research. This study has emerged from the need to make the analysis process faster and more objective, and thus more usable in clinical settings.

The first aim of this research is to automatically analyze musical features of music therapy improvisations by clients with mental retardation, and to compare these

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features with assessments done by therapists. The second aim is to automatically analyze musical communication of clients and therapists in terms of synchronitcity, soloist-accompanist-ratio and turn-taking.

The research is carried out in collaboration with three districts of services for intellectually disabled (Pääjärvi, Satakunta and Suojarinne) and the Rinnekoti-Foundation where music therapists collect MIDI improvisations as a part of their daily clinical work.

Client improvisation data is analyzed with a Matlab toolbox that has been developed for the extraction of musical features from MIDI. This process is based on previous research on cognitive musicology at the University of Jyväskylä, which has produced computational algorithms for the analysis of rhythm (Toiviainen, 1998), melody (Eerola, Järvinen, Louhivuori & Toiviainen, 2001) and tonality (Krumhansl and Toiviainen, 2000).

Evaluations done by therapists are collected immediately after each improvisation with help of web forms.

Data collection will continue until January 2005, but preliminary results and implications will be presented at the 6th European Music Therapy Congress in June 2004. This ongoing research work is part of research project Intelligent Music Systems in Music Therapy, funded (code 102253) by Academy of Finland and conducted by Ph.D Petri Toiviainen and Ph.D. Jaakko Erkkilä.

Aims of this study This study is part of the Intelligent Music Systems in Music Therapy project. The purpose of this study is three-fold. The first goal is to develop a procedure for collecting music therapy improvisations. Second aim is to test usability of an automatic computer-based MIDI analysis system of musical features in the clinical setting. Thirdly, after collecting and analyzing these improvisations, possible connections between clinical and musical variables will be investigated computationally.

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Institutions involved

Institutions involved Four institutions for intellectually disabled are involved in this study by giving human and material resources in the form of investing in equipment needed and letting music therapists use their time for gathering data from their daily clinical work.

A total of five qualified music therapists from four institutions are participating in this study. They are:

• Pääjärvi Federation of Municipalities: music therapists Kimmo Pyhäluoto and Leila Varkila

• Rinnekoti-Foundation: music therapist Heikki Raine • Satakunta District of Services for Intellectually Disabled: music therapist Arto Mäkelä

• Suojarinne Federation of Municipalities: music therapist Jukka Värri

Use of improvisation in music therapy Improvisation is a common method in music therapy practice. Improvisational music therapy has been applied to a large selection of clinical populations including intellectually disabled persons (Bruscia, 1987, 5-6).

Previous research of music therapy improvisations has been based mostly on recording, transcription and interpretation of improvisations. Utilizing sequencer and notation software has been described in recent years (Orsmond & Miller, 1995; Lee, 2000; Wentz, 2000).

This research is an attempt to use automatic extraction of musical features in the area of music therapy improvisation analysis in clinical setting. If the automatic extraction of musical features turns out to be applicaple for this purpose, it will allow analysis of large amounts of data in a short time interval. In the future, that will provide a more effective method of comparing music therapy improvisations of various diagnostic groups as well as improvisations during therapy of a particular client.

Practicing clinicians can expect automatic musical feature extraction software to be used as an evaluation tool for clinical work in the future.

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Improvisational music therapy has been used with various clinical populations, including mental retardation, learning disabilities and neurological impairments (Bruscia, 1987, 6).

Because of its wide clinical use improvisation is also used in music therapists´ education. Erkkilä (2000) has made a proposition for the didactics of music therapy improvisation, where theory and experience is combined.

In the realm of neurological conditions music therapy improvisation as a source for assessment data has been a subject of interest in Alzheimer´s disease (Aldridge, 2000) and spinal cord injury (Amir, 1990).

Bruscia (1991) has edited a collection of case histories, where improvisation is reported to be used in 26 cases out of a total of 42.

Besides numerous case histories, effects of music therapy improvisation have been researched more extensively. Edgerton (1994, 33) developed a checklist (CRASS) to evaluate communicative behavior of autistic children (n = 11) from video recordings, and found that improvisational music therapy was more effective than a reversal mode of structured music therapy where pre-composed tunes were used instead of improvised music.

Formisano, Vinicola, Penta, Matteis, Brunelli and Weckel (2001, 627) reported that active improvised music therapy improved collaboration and reduced undesired behavior of comatose, severe brain-injured patients (n = 34).

Burns, Harbuz, Hucklebridge and Bunt (2001, 48) compared outcomes of improvisational and listening-based music therapy for cancer patients (n = 29) and found increased experience of well-being and energy, less tension during improvisation, and measured increased level of salivary immunoglobulin A and decreased level of cortisol in both groups.

Effect of improvisational music therapy in the field of psychiatry has been examined by Maler, von Wietersheim, Schurbohm, Nagel, Feiereis and Jantschek (1994, 122); analysis by means of specially constructed rating scales revealed that patients with psychiatric and psychosomatic disorders (n = 200) played louder, were more free in the improvisation and showed more plasticity after 10 sessions of music therapy.

Pfeiffer, Wünderlich, Bender, Elz and Horn (1987, 184) conducted a controlled study with therapy group of patients (n = 7) with diagnosis of schizophrenia or

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Development of improvisation analysis technology

schizoaffective psychosis participating in 27 sessions of free improvisation music therapy and a matched waiting group. Therapy had no effect on psychopathological picture measured on Lorr scales, or on recreational and social behaviors.

Pavlicevic and Trevarthen (1989) developed a rating scale (MIR) to compare improvisations of schizophrenics (n = 15), depressed patients (n = 15) and normal controls (n = 15) and found significant differences in the improvisations of these groups. Pavlicevic, Trevarthen and Duncan (1994) developed further the previous MIR rating scale to evaluate communication of schizophrenic patients. According to the researchers, the therapy group (n = 21) who attended 10 weekly music therapy sessions improved their clinical status and the level of musical interaction measured on MIR(S) scale in comparison to the control group (n = 20) who attended only the first and last sessions.

Bruscia (1987) has developed the IAP model of assessment which demands aural musical analysis of recorded improvisations, and is designed to be used within not one but many possible kinds of interpretations. The large scale and complexity of the model has been a source of discussion and Bruscia (2001) has presented the abridged version of the IAP.

Development of improvisation analysis technology In the beginning music therapy improvisation analysis was by using a reel-to-reel tape recorder, pencil and an empty sheet of music. This method takes so much time that it is rarely used by practicing clinicians.

Some analysis methods rely on graphic notation like Bergstrøm-Nielsen´s (1993) approach. Recording technology has been developed, and saving improvisations on computer´s hard disk as MIDI files instead of using analog tape recorders has been a rising trend. Orsmond and Miller (1995) used MIDI recording technology in their study concerning the charasterics of improvisations of children with developmental disabilities. Lee (2000) presented his method of analyzing music herapy improvisations using MIDI recording and software notation as one possibility instead of tape recording and manual transcription into notation. The process in whole in Lee´s model is phenomenological and includes many interpretative stages. Wentz (2000) has utilized MIDI recording and the use of notation software in context of NordoffRobbins music therapy.

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In spite of exploiting computer technology in recording and notation music therapists have not used technology in automatic analysis of collected improvisation data. Research of computational modeling of musical processes in the realm of cognitive musicology can help to achieve this goal. Many of these models can directly be applied to algorithmic analysis of music. At the University of Jyväskylä the research of cognitive musicology has produced computational algorithms for analysis of rhythm (Toiviainen, 1997, 1998; Toiviainen and Snyder, 2000, 2003), melody (Järvinen and Toiviainen, 2000; Krumhansl, Louhivuori, Toiviainen, Järvinen and Eerola, 1999; Krumhansl, Toivanen, Eerola, Toiviainen, Järvinen and Louhivuori, 2000); Eerola, Louhivuori, Järvinen and Toiviainen, 2001) and tonality (Krumhansl and Toiviainen, 2000).

Development of music therapy improvisations collecting procedure Improvisations are collected by music therapists as a part of their daily clinical work at institutions for intellectually disabled. Clients in this study are clients with mental retardation, some other neurological diagnosis, or some psychiatric diagnosis. This is due to increased functional capacity of large units those inhabitants have during years moved to more independent life to smaller units.

Therapist and client improvise together with two separate MIDI keyboards. Unfortunately, the keyboards used have been proven to be of poor technical quality and shall be replaced with keyboards of higher standard. Time or content of improvisation is not limited. Timbre is limited to piano sound because MIDI data does not store information of timbre. A MIDI sequencer software is used to record improvisation. After improvisation has completed therapist exports it in .MID-format as two independent MIDI tracks, track 1 played by the client and track 2 by the therapist.

From there he or she sends it to the researcher. Transmission is web-based. In addition to MIDI files therapist fills in complementary data.

Basic abilities of clients are assessed by a MIDI music test that has been constructed to serve needs of this particular study.

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FIGURE 1.

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FIGURE 2.

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Development of music therapy improvisations collecting procedure

FIGURE 3.

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FIGURE 4.

.

At first time of the first improvisation, the therapist fills in the basic data form which includes basic information e.g. about diagnosis. and verbal abilities. The fol-

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low-up form, that will be filled in every third month, is very similar. After every improvisation, the therapist is required to fill in the improvisation analysis form which includes ratings concerning the client´s musical and nonmusical functioning during the session. These evaluations done by therapist compliment the information received from MIDI files.

Relation of automatic analysis system to subjects of clinical interest Music Therapy Toolbox (MTTB) is a set of MIDI Toolbox (Eerola & Toiviainen, 2004) functions for MATLAB software. MTTB is still at the developmental stage, and more functions will be included and developed in the future.

According to the World Federation of Music Therapy (1996) the function of music therapy is to meet physical, emotional, mental, social and cognitive needs.

Clients with physical needs can have problems in dexterity of upper limbs. These difficulties affect the client´s operating area at the keyboard. MIDI data reveals which keys have been pressed during improvisation. Clients who have problems in motor dynamics play the keyboard either without dynamic nuances or use extreme force. This category of problems includes lack of force as well. In MIDI data, velocity value has a ratio to the player´s use of dynamics. Also differentation of fingers can be detected from the MIDI data by looking if there have been played separate keys or clusters. In evaluating MIDI data it is useful to remember that actions can be intentional or not. That is the reason for performing the MIDI test before beginning the actual improvisation sessions. If the client can differentiate his or her fingers but will not do it in improvisation, therapist has a reason to conclude that playing of clusters is a delibarately performed action.

Emotional content of improvised music is a clinically important subject when therapy has emotional or mental dimensions. According to Sloboda and Juslin (2001, 81-82) there are two kinds of (not totally independent) musical emotions: those concerning the aesthetical value of music, and those induced or expressed by music. Gabrielsson and Lindström (2001) have reviewed the research literature concerning the influence of musical structure on emotional expression. Concepts and terms of many researches used in studies since the 1930´s are miscellaneous, but many of them are the same as Juslin (2001) has summarized in his presentation of structural components of performers´ emotional communication in music grouped in five emotional categories where is the (tenderness, happiness, sadness,

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fear and anger being in relationship with dimensions of valence and activity level.

Several structural components are partly overlapping in these emotional categories.

Cognitive abilities of a client are apparent in their perception of the instrument and situation as well as in reacting to events. These include hearing and memorizing skills. These can not directly be derived from improvisational MIDI data but are present in communicative actions between client and therapist.

Musical features of social functioning in improvisation situation can be detected by comparing client´s and therapist´s actions. They can be viewed in graphs of MTTB to find correspondencies in musical features between players. Signs of leading and following can also be seen in graphs. These are especially relevant if client´s problems are related to extreme expression of dominance or submissiveness.

MTTB creates a set of graphs. First there are pianoroll windows which represent the content of selected MIDI channels in ascending order. In this case, the therapist´s channel is number 1 (blue or) and the client´s channel number two (red).

Pitch windows give an overall impression of music played.

Density refers to amount of notes per second. Usually, but not always high density is perceived in music with fast tempo, and low density with slow tempo. Fast tempo has in most studies been interpreted a sign of happy emotion, and in some cases anger or fear (Gabrielsson & Lindström, 2001, 235-239).

Mean duration refers to duration of notes played.

Mean pitch gives information about the register participants have used during improvisation.

Pitch standard deviation tells also about use of registers but in smoother manner than previous graph.

Mean velocity refers to speed of tone attacks.Velocity sensitivity is the keyboard´s responsivity to the speed which a key is depressed. Velocity sensitivity has a ratio to the dynamics used by a player. Loud sound level in music has been interpreted as an expression of joy, gaiety or anger by listeners, while soft sound level has been represented as expression of sad-toned or tender emotions or fear in various studies reviewed by Gabrielsson and Lindström (2001, 236-240).

Large variations in loudness have been interpreted as expression of fear and small variations have represented happy and active emotion (Scherer & Oshinsky, 1977).

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Emotional interpretation of loudness changes has been more a controversial subject (Gabrielsson & Lindström 2001, 236-237)).

Pulse clarity function is still under development being a rather tentative measurement at the moment. Pulse clarity tells us about rhythmic regularity. Gabrielsson & Lindström (2001) have summarized studies concerning emotional interpretation of rhythm. Regular, smooth and flowing rhythm has been interpreted as a sign of happy emotion (although in one study varied rhythm was interpreted as joyful).

Irregular, rough and complex rhythms represent controversial matter of expression to listeners, sometimes being labeled as happy, sometimes as angry, and sometimes as sad.

Tonal clarity graph refers to the grade of tonality but not in a certain key. This means that the tonality of improvisers can be as well in the same or different key.

Plans to develop MTTB include inserting a major/minor tonality function in toolbox because of vast evidence of major/minor tonality contributing to emotional interpretation of music. This idea has been reviewed extensively by Gabrielsson & Lindström who have summarized studies confirming that listeners connect tonal music to happiness, atonal music to anger and chromatic music either to sadness or to anger (2001, 234-241). Kennedy(1980, 660) has defined tonality as key, meaning particular observance of a single tonic key, and atonality as loyalty to no key.

Articulation presents a value equal to 1 minus silent moments in the current window. According to this articulation gets a small value if there is much silence in the window.

It´s useful to keep in mind that this articulation window does not refer to staccato or legato articulation but rather to amount of activity.

Timbre can not be analyzed beacause MIDI information does not include information of it.

At the present moment this study is still in its infancy. Data collection has begun, but in the shadow of technical problems mentioned previously. These obstacles are not insummountable, and hundreds of improvisations with incidental form data is expected to get collected and analyzed during the study. Until this work is completed it is too early to predict which the possible findings will be.

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References Aldridge, G. (2000): Improvisation as an assessment of potential in early Alzheimer's Disease. in Aldridge, D. (Ed.): Music Therapy in dementia care: More new voices. Jessica Kingsley, London (pp. 139-165).

Amir, D. (1990). A Song Is Born: Discovering Meaning in Improvised Songs through a Phenomenological Analysis of Two Music Therapy Sessions with a Traumatic Spinal-cord Injured Young Adult. Music Therapy, 9 (1), 62-81.

Bergstrøm-Nielsen, C. (1993). Graphic Notation as a Tool in Describing and Analyzing Music Therapy Improvisations. Music Therapy, 12 (1), 40-58.

Bruscia, K. E. (1987). Improvisational models of music therapy. Springfield, IL: Charles C. Thomas.

Bruscia, K. E. (1991). Case studies in music therapy. Gilsum, NH: Barcelona Publishers.

Edgerton, C. L. (1994). The effect of improvisational music therapy on the communicative behavior of autistic children. Journal of Music Therapy, 31 (1), 3162.Burns, S. J., Harbuz, M. S., Hucklebridge, F. & Bunt, L. (2001). A pilot study into the therapeutic effects of music therapy at a cancer help center. Alternative therapies in health and medicine, 7 (1): 48-56.

Eerola, T., Järvinen, T, Louhivuori, J. & Toiviainen, P. (2001). Statistical features and perceived similarity of folk melodies. Music Perception, 18 (3), 275-296.

Eerola, T, & Toiviainen, P. (2004). MIDI Toolbox. MATLAB Tools for Music Reasearch. Jyväskylä: Department of Music, University of Jyväskylä, Finland.

Erkkilä, J. (2000). A Proposition for the Didactics of Music Therapy Improvisation.

Nordic Journal of Music Therapy. 9 (1), 13-25.

Formisano, R., Vinicola, V., Penta, F., Matteis, M., Brunelli, S. & Weckel, J. W. (2001). Active music therapy in the rehabilitation of severe brain injured patients during coma recovery. Annali dell´Istituto Superiore di Sanita, 37 (4), 627-630.

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References

Gabrielsson, A. and Lindström, E. (2001). The influence of musical structure on emotional expression. In P. N. Juslin and J. A. Sloboda (eds.) Music and emotion theory and research. Oxford University Press, Oxford.

Järvinen, T. & Toiviainen, P. (2000). The effect of metre on the use of tones in jazz improvisation. Musicae Scientae, IV/1, 55-74.

Kennedy, M. (1980). The Concise Oxford Dictionary of Music. Third edition.

Oxford University Press, London.

Krumhansl, C. L., Louhivuori, J., Toiviainen, P. , Järvinen, T., & Eerola, T. (1999).

Melodic expectation in Finnish folk hymns: Convergence of statistical, behavioral, and computational approaches. Music Perception, 17 (2), 151-196.

Krumhansl, C. L., Toivanen, P., Eerola, T., Toiviainen, P., Järvinen, T. & Louhivuori, J. (2000). Cross-cultural music cognition: Cognitive methodology applied to North Sami yoiks. Cognition, 75, 1-46.

Lee, C. L. (2000). A Method of Analyzing Improvisations in Music Therapy. Journal of Music Therapy, 37 (2), 147-167.

Maler, T., von Wietersheim, J., Schurbohm, E., Nagel, A., Feiereis, H. & Jantschek, G. (1994). Beschreibung des musikalischen Ausdrucks und erste Ergebnisse im Lübecker Musiktherapiemodell. Psychotherapie, Psychosomatik, medizinische Psychologie, 44 (3 - 4), 122-127.

Juslin, P.J. (2001). Communicating emotion in music performance: a review and theoretical framework. In P. N. Juslin and J. A. Sloboda (eds.) Music and emotion theory and research. Oxford University Press, Oxford.

Orsmond, G. I. & Miller, L. K. (1995). Journal of Music Therapy, 32 (3), 152-166.

Pavlicevic, M. & Trevarthen, C. (1989). A musical assessment of psychiatric states in adults. Psychopathology, 22 (6): 325-334.

Pavlicevic, M., Trevarthen, C. & Duncan, J. (1994). Improvisational Music Therapy and the Rehabilitation of Persons Suffering from Chronic Schizophrenia. Journal of Music Therapy, 31 (2), 88-104.

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Pfeiffer, H., Wunderlich, S., Bender, W., Elz, U. & Horn, B. (1987). Freie Musikimprovisation mit schizophrenen Patienten - Kontrollierte Studie zur Untersuchung der therapeutischen Wirkung. Rehabilitation, 26 (4), 184-192.

Scherer, K.R. & Oshinsky, J.S. (1977). Cue utilization in emotion attribution from auditory stimuli. Motivation and Emotion, 1, 331-46.

Sloboda, J. A. and Juslin, P. N. (2001). Psychological perspectives on music and emotion. In P. N. Juslin and J. A. Sloboda (eds.) Music and emotion theory and research. Oxford University Press, Oxford.

Toiviainen, P. (1998). An interactive MIDI accompanist. Computer Music Journal, 22 (4), 63-75.

Toiviainen, P. & Snyder, J. (2000). The time-course of pulse sensation: Dynamicsof beat induction. In C. Woods, G. Luck, R. Brochard. F. Seddon, J. A. Sloboda (Eds.), Proceedings of the Sixth International Conference on Music Perception and Cognition. Keele: Keele University.

Toiviainen, P. & Snyder, J.S. (2003). Tapping to Bach: Resonance-based modeling of pulse. Music Perception, 21 (1), 43-80.

Toiviainen, P. (1997). Modelling the perception of metre with competing subharmonic oscillators. In A. Gabrielsson (Ed.), Proceedings of the Third Triennial ESCOM Conference. Uppsala: Uppsala University, 511-516.

Wentz, M. (2000). Entwicklung einer computergestützen Methode zur graphischen Darstellung musikalisch zeitlicher Interaktionen zwischen Therapeut und Patient zur Verwendlung in der Nordoff/Robbins-Musiktherapie. Diplomarbeit. Institut für Musiktherapie, Universität Witten-Herdecke.

World Federation of Music Therapy. (1996). Definition of Music Therapy. http:// www.musictherapyworld.net/

Author information Kari Riikkilä M.A., music therapist

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Author information

University of Jyv채skyl채, Department of Music PL 35 (A313), 40014 University of Jyv채skyl채, Finland katariik@cc.jyu.fi

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Music Therapy Today, Vol. VI, Issue 4, (November 2005) a publication from MusicTherapyWorld.net

CHAPTER 46

Voices of authenticity and integrity: A music therapist’s self-inquiry in working

with children facing a lifethreatening illness.

Roberts, Ruth J.

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Introduction Children who are diagnosed with a life-threatening illness are thrown into a world of turbulence where all inner and outer resources are challenged.

Cancer, the second leading cause of death in childhood, requires aggressive and extensive treatment. There are many types of cancer each with its own set of challenges, treatments and outcomes.

For the past 5 years I have worked on a paediatric oncology ward. It has been my privilege to work directly with children and their families as they negotiate their way through lengthy treatment protocols and frequent hospitalizations. It is important that music therapy serves as a strengthening, life-giving force to assist such children on their paths. In music therapy a place is offered where fears, anxieties, grief and pain may be acknowledged and held. Here a child finds opportunity to create beauty and life in the midst of suffering.

Although most children are treated successfully, each year approximately 60 children in the Oncology program die. I often work with the children and families as the child's life ends. Although there is not a palliative care unit in the hospital, a two/day week music therapy program has been initiated to offer service to children receiving palliative care at home. Children served include those with metabolic, neurological or genetic disease.

Nothing in life fully prepares one to accept the death of a child, a human being full of promise and hope. Bearing witness to the suffering and death of a child is no small task. In this process it is important that I, as therapist, am not overwhelmed by the enormity of the need or the ensuing painful emotions the work inevitably evokes. It is incumbent upon me to remain strong and healthy within my own body and spirit so that I may have the capacity for the work. Among other challenges this work demands an ability to be fully present, to be vulnerable and to be authentic.

The purpose of this Masters research is to conduct an in-depth analysis of my perspectives and responses in caring for acutely ill and dying children and in particular to explore elements of authenticity and integrity in the work.

For purposes of the study, integrity is defined as: ‘soundness, the quality or state of being complete or undivided, and completeness’ (Webster’s Collegiate Dictionary, 1993). I am asking: What does the work teach me about soundness and completeness? How can I be sound and complete in order to do this work well?

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Epistemology

Authenticity is defined as ‘not false: real, actual; true to one's own personality, spirit or character’ (Webster’s Collegiate Dictionary, 1993). I am asking what does the work teach me about being real and how can I be true to myself in this work?

In my practice I found that the usual clinical form of writing and reporting did not express the essence of what was transpiring in the sessions. I observed that there were things going on, ‘important things that I could not acknowledge’ (Bereznak Kenny, 1998, p.204). I felt the need to "find a language which more accurately described my experience with clients” (p. 211). .

While comparing aspects of various research methodologies, I learned that poetic transcription is “the creation of poem-like compositions from the words of interviewees, and re-presenting or re-framing a story into a creative form of writing” (Donnell, 2003). For some time I have been describing clinical work in creative narrative form/poetic form as a means of satisfying my need for self-expression and self-care. As I reviewed some of these writings, I realized they were a rich resource for my quest, and that, indeed, I had a language which was congruent with my clinical experience.

Recently, I have incorporated sketching into my personal self-care practise. Drawing images related to painful or meaningful personal and professional experiences has given rise to additional insights and inner healing. I have chosen to include some of these in this work.

In this research paper as I explore issues of authenticity and integrity I ask: What are the elements of authenticity and integrity in this work?

How do I foster it in myself and my clients?

How can I convey the essence of the work in an authentic, integrated way?

Epistemology As a qualitative researcher I bring a unique perspective to this study, shaped by beliefs and values, both personal and professional.

I believe that connecting with people in a meaningful way presents opportunity for healing and growth. When one human being is truly present to another without an

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agenda, doors are opened. I believe the answers lie within; it is best that people, when given support and opportunity, find their own way, rather than be directed by another- and that this approach affords the greatest respect to another human being.

I have deep respect for the wisdom of children and believe that they teach us much about what is truly valuable in life. I believe that the each human being is called to create and that we are born with an innate yearning and ability to do so and that it is necessary to health.

I believe that the worth of each human is immeasurable and that the significance of their existence, however long or short, is eternal. I believe that music is one way the eternal is represented in each human being.

I believe in the power of story. Story is a way of expressing the essence of experience, and placing it within a greater life context. I believe it is vital to effective music therapy that I pursue my own quest for integrity and wholeness in order to remain vibrant and to facilitate growth and healing for my clients. “Making ourselves whole is an ongoing process” (Bereznak Kenny, 1998, p. 215).

Methodology This is a qualitative descriptive study. It is concerned with process rather than outcome and evolves from my own work. It describes experiences, asks open-ended questions and can be adapted as the research develops. My position as a researcher includes ongoing self-reflection; my subjectivity is considered a resource. My motivation for this study is as a professional caring for very ill children. And the data reflects a real-life clinical setting.

The study contains elements of heuristic, adapted phenomenological and narrative methods.

Heuristic methodology is a ‘process of an internal search through which one discovers the nature and meaning of experience’ (Moustakas, 1990, p. 12). In revisiting the data I am committed to ongoing introspection, reflection and interaction with the text. I do not maintain a safe distance or assume an objective stance. But immerse myself in the data, interacting with it on various levels. I am committed to ‘risk the opening of wounds and passionate concerns and to undergo the personal transformation that exists as a possibility in every heuristic journey” (Moustakas, 1990, p. 14). I am applying the intuition I have gained from many years of life, professional experience and commitment to my inner healing, spiritual and psycho-

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Methodology

logical growth. I am investigating in new ways, examining stories, poetry and the pastel sketchings which were created as part of my professional and personal journey.

This study employs three types of adapted phenomenological methods: Applying the reflective method I use my own experience as data to engage in a process of reflection and clarification while attempting to describe the essence of the experience. Empirical methods include reading descriptions, extracting significant statements, finding themes, categorizing and formulating meanings.

In addition, I describe the experience faithfully and engage in an internal dialogue to uncover multiple descriptions the encounter (Young, 2003).

Narrative inquiry is a way of knowing defined as the telling of one's story. In this telling, one seeks to present experience in order to clarify, justify and find meaning (Nye, 1997 p. 441). In using this method I uphold ‘the value of learning to hear story through music and finding ways to bring this into our research efforts" (Aigen, 1996, p. 30). The stories are not only presented as data to be analyzed and categorized but be engaged in.

DATA COLLECTION

The source of my data is secondary. Materials include poems, stories, and sketchings done in response to specific naturally occurring experiences during the course of my clinical work.

I reviewed six pieces of writing done over a period of two years. These writings are direct accounts and selected from a collection of writings that were written spontaneously following experiences that were significant to me in my clinical practise.

Data generated by the research includes levels of ensuing dialogue with the original text. Some sketches were a spontaneous expression in response to my clinical work; others were generated by the research process as I revisited the stories, thereby providing additional data.

Using various art forms to process internal issues is congruent with the work of music therapists. I use the art forms of creative writing and pastel sketching to preserve the integrity of my experiences as well as to communicate them.

By preserving my experiences in story form over time I accumulated potential data.

Over time, I observed the nature of the unfolding stories as a whole.

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DATA ANALYSIS

The data was analyzed on different levels. I followed Husserl’s phenomenological ‘free fantasy variation’ by revisiting the clinical stories through imagination, intuition and further dialogue (Bereznak Kenny, 1989, p. 61) for purpose of gaining perspective, identifying themes, coding and categorizing. The essential elements gleaned reflect only my view and interpretation, not the clients.

The data was analyzed through peer checking – in a research workshop with 6 Masters students and 2 Music therapy Professors. I submitted the stories to two PhD supervisors who reviewed the data and checked my analysis. The categories were then revisited and data reconsidered to reflect final changes.

The stories follow and are accompanied by the result findings. All names are pseudonyms. a) Three of the six stories used in the original masters paper are included in this presentation. Each story or piece of writing is presented in its entirety. Two of the stories include subsequently added dialogue with the text, revealing my remembered emotional responses including those evoked on re-reading. One of the stories has a short reflection added following the original text. b) Six voices of authenticity, as identified in the data, are presented: paradox, struggle, life, spirit, self and music. c) Relevant literature and existing resources are considered in relation to the text and issues that arise from it. d) Sketches with commentary are included throughout.

STORIES VERA AND GINA

All three children in one family I see have had neuroaxonal dystrophy - a rare genetic disorder in which a child develops normally until toddler hood, and then gradually irreversibly loses all neurological and physical functioning. I met this family, six months following the death of their ten-year-old son and a year after their youngest daughter started showing symptoms. Their thirteen-year-old daughter remained alive, with no external visible response. Both girls required twentyfour hour nursing care.

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I provided a listening environment for Gina, the older child. Initially Vera, who is 3, was able to attend to music by turning her head, with occasional facial expression and vocalization. In the ensuing months she lost even this ability to respond.

REFLECTIONS

Music therapy in this home presented me with one of my greatest challenges. I knew the children would not recover – that they could live more years or might die at any time. I could not assess music therapy given usual standards. However, in time, I came to realize the significance of the must her for their mother…that by offering the girls music therapy I was agreeing with that their lives were indeed, invaluable and that they were worthy of something lovely and beautiful.

Mom shared pictures of her children as happy vibrant toddlers prior to the onset of illness. As I sang to the girls I could easily imagine them as beautiful children at play. I often felt a sense of connection and would sing to them of their loveliness.

One day I had an experience which stood out in my memory as significant yet I found myself reluctant to write about it because it wasn't ‘clinical’ and because it defied language.

I was providing instrumental guitar music…. wind chime music…. Matching in and out respirations with 2 note step-wise melodic vocal phrases.

“Later I held her hand and sang in a meditative style….

I began singing of a 'little pink flower’, attempting to relate to Gina’s spirit, as her mind and body were not capable of reaching out.” The music was a celebration of her beauty, loveliness and innocence.

Is there a time when the client’s music is created through us? My sense was that this was such a time. Through a deeper connection, which I choose to call spirit, I was able to give voice to her 'flower song’. In this way I served as a vessel because she was not capable of singing her own song.

SKETCH

During the writing of this paper Gina died – I had not been working with her as I was off for a year to attend school. In reflecting on her life and death, and as a personal tribute I did a sketch. For me it expresses the essence of Gina a ‘little pink flower’ - her spirit open and freed, its essence ever expanding on its rise to eternity.

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When I returned to work after my studies, Mom showed me many pictures of the funeral. Gina lay in her coffin, dressed in a simple white dress. Then I noticed the material. It was patterned with little pink flowers.

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FIGURE 1.

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In the following story you will hear my voice reading the original text and a second voice, which is my response as I began interacting with the text.

BOCELLI, BEETHOVEN AND A BOY

Saheem was a 14-year-old boy undergoing chemotherapy for cancer and had demonstrated autistic tendencies throughout life. He lived in a loving home with dedicated, caring parents.

It feels so strange to be introducing him by his diagnosis, because I honestly don't think of children in this way. It's such a relief from my days of nursing. In music therapy I am free to identify people by their potential rather than their pathology.

The first time I saw Sachem he announced that he liked classical music and could play the piano.

His enthusiasm was infectious.

Unfortunately I do not have a music therapy room or a piano, but there is a small keyboard on the unit. He was thrilled when I gave it to him for use during his hospitalization. The nurses enjoyed his music and saw another side to this boy they knew medically.

The music opens up more of a person, so the staff can appreciate a child in new ways. By giving expression to this vital part of him, Saheem was validated and reminded of who he was.

On this particular day Saheem invited me to view a video of Andre Bocelli, his favourite opera singer. Together we listened to the performance of “Time to say Goodbye”. As he listened, tears streamed down his face.

I remember thinking…”Well this isn't really music therapy because a) It’s a tape and b) I'm not 'doing' anything. (These music therapy police rear their ugly heads often during the course of my work!)

Dad, a lovely and gentle man said, "Ruth, lately he's been crying when he hears it…. maybe it’s related to the words.”

I was moved and touched by this man's sensitivity and gentleness. He knew how to just 'let it be'. He had no need to intervene in his son's private moment. A child's pain indeed can be a terrible and frightening thing. Sometimes an added burden for the child during such illness is a need to spare their loved ones pain.

Giving expression to some inner sadness which music listening allowed, was important for Saheem to do.

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STORIES

Saheem had a wonderful sense of fun and gusto. One day his hair began to fall out, an expected side effect of the chemotherapy.

I waited to see his reaction.

He picked up a strand or two from his pillow and announced, with great excitement “HEY, my hair is falling out."

I anticipated some expression of anxiety and wondered what would come next.

Then he thought a moment and said, "HEY DAD, Beethoven was deaf, Bocelli is blind AND I'M GOING BALD!" We burst out laughing.

A few moments later he mused…

"A deaf composer, a blind singer and a bald pianist.”

This unabashed humour was completely unexpected and wonderfully refreshing.

It speaks of S's vibrant playful spirit, which remained very intact in the face of losing his hair, an experience that can be a threat to a child’s self-image. Saheem knew that his place and he clearly ranked in the company of other great musicians!

MELISSA

I met Melissa as a beautiful 18-month-old child. Her parents had been given the news 6 days earlier that there was nothing more that could be done medically to treat her brain tumour. Her life expectancy was four to six weeks. I visited her twice in her home. The first time, after an initial period of shyness, she responded very strongly to the music. Curious and inquisitive, she gathered all her favourite instruments near. She beat steady rhythms on the lollipop drum. And smiled and directed mom to play the drum.

It was hard to believe that she was only expected to live a few more weeks.

Soon mom, Melissa and I were making rousing, beautiful music. She threw her arms over her head in jubilant delight. ...Moments of joy....

Four days later, she was showing signs of deterioration, with obvious increasing CNS (central nervous system) impairment.

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Her mom was clearly in shock and distress. She child and had been with her day and night since birth.

Four days later Melissa was hospitalized for pain management. Greeted by her mom in the hospital hallway I noted how thin she felt in my arms - this little mother, who was being forced to relinquish her only child. Melissa was being held by her father. Grandma, newly arrived from China, was nearby. Sisters, cousins, relatives from near and far moved and out of the room. Dad constantly stroked Melissa. Her parents spoke freely of her loveliness expressing amazement at how quickly she had deteriorated. They talked of what a special child she was - how everyone was drawn to her.

Even though Melissa’s life was so short, this remembering was a necessary preparation for those she would leave behind.

Mom stated that 'this' has brought the family together, created a strong bond.

I felt mom was struggling to find some greater meaning in the tragedy.

Grandma had arrived from China on Monday and it was as if Melissa had known her instantly. She smiled and laughed " more than I've heard her laugh in a long time”, Mom said.

Mom had only met grandma once. Melissa had never met grandma before. This meeting and instant 'knowing' between them brought comfort to mom.

The day after her visit with Grandma Melissa quickly deteriorated. What a wonderful gift that grandma arrived in time to share in the beauty of this little person!

In the hospital room Melissa’s parents played her favourite Mozart CD, smiling, laughing and remembering her life. "Maybe she's an angel who was sent for a little while", mom mused.

I recall their commitment to moving heaven and earth to help their child.

I recall the encroaching despair when nothing was enough.

I talked to the family of how she loves them too. I listened to them revel in their daughter's uniqueness and beauty. We spoke of her remarkable affinity for music; we remembered the way she knew immediately what sounds she liked or disliked, how well she communicated, without words, Her parents had started a piano fund.

It was such an honour to know this little person...

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STORIES

As the music ended, I started to sing quietly to Melissa, who was asleep, perhaps unconscious, in her dad's arms. Melissa you are beautiful”, and "Thank you for coming”, adding out loud, “Even though it wasn't long enough”.

“Your voice is so soothing”, mom said.

I asked, “Could I bring my guitar?” They were very happy for me to do so.

I returned with the guitar. At the sounds of the first strums everyone came into the room gathering around Melissa.

The music was bringing them together.

Dad constantly rubbed her head and cheeks saying, "I wish I could just touch the tumour away".

A father’s anguish...

Some wiped away tears to the strains of lullabies and peaceful, soothing songs.

Mom broke the mood by saying - "If Melissa was awake she would say, 'YEAHHHHH", as she threw her arms over her head.

We laughed then moved to upbeat celebratory music, then mom, recalling how Melissa loved the bells and the drum, gathered the lollipop drum, tambourine, shaker and handbells. Mom took the drum and began to beat. Soon both grandmas picked up an instrument and added rhythms to our music.

We continued. I improvised and the music surged and swayed. Although we could not speak the same language we were together in the music supporting this child, giving her strength I hope for her journey and while holding her parents as they could only watch her go.

It seemed mystical.

As the music closed grandma gave a final cadential shake of the colourful seed shaker. Everyone laughed and smiled.

But the Grandmas continued…playfully picking out music.

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Dad explained, "They are remembering the music from when they were young, in the 50's in China…"

Ahh....more remembering ...across the generations...

There was something lovely, in that moment. This beautiful child, surrounded by love and celebration and music, and laughter and tears… This child, destined for another place was surrounded with the love and music of her family, her ancestors.

A close family friend arrived with two pairs of new shoes…lovely little pink sandals, and nice dress shoes...

"She will need those in the summer” said her mom.

"They will go with her."

The burial ritual of sending the body off with gifts was not widely understood among the staff. Some were afraid that mom was in some form of denial. I might have wondered the same had I not known her and her religious beliefs.

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FIGURE 2.

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Voices of Authenticity and Integrity Initial analysis of the stories revealed several categories defined by specific phrases that emerged from examining the data. From the initial analysis six voices are identified and described: paradox, struggle, life, spirit, self and music.

VOICE OF PARADOX

Working with very ill or dying children presents a profound juxtaposition of opposing realities:

• • • • • • • • •

Laughter in the face of adversity Adult wisdom in a small child Celebration and play in the midst of sorrow Order within chaos A vibrant spirit in a dying body Time/Timelessness Holding on/Letting go Hope against hope Reality in fantasy.

Bereznak Kenny writes, "When paradox exists, perhaps it is best to embrace, articulate and elaborate on its elements rather than avoid them” (1996, p. 63).

Paradoxes are woven through all the stories.

The courage of each child and family to face and embrace paradox serves to teach me as a therapist to so the same.

VOICE OF STRUGGLE "Look long and hard at the things that please you Look longer and harder at the things that cause you pain."

(Colette in Sourkes, 1995, p. 167)

The authentic voice is one of struggle. Parents struggled to face each day in choosing life over death and I struggled to hear the laments - to bear witness to the tears, sadness, anguish - to endure the unknowing and to stay present. I struggled to make sense of that which was not sensible. Even as I knew each child’s beauty and

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revelled in their joy, I struggled to understand how they could suffer and die. I struggled to know why families who battled through years of illness in the end had to watch their child die. I struggled to accept that there are no answers.

SKETCH

At one point I grew “sick and tired of babies dying”. I sketched tiny forms with big black X’s obliterating – a black force sweeping down to carry them off.

Yet there are hues of pinks and blues - hints of my belief that they are in a better place.

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FIGURE 3.

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VOICE OF LIFE

Many words of life were gleaned from the stories: Play/Dance Joy Aliveness Sweetness Exuberance Choosing life Laughter Fully alive Humour Fantasy Simplicity Loving Children, unlike adults, remain very close to play even when they are very ill. Their imaginations are easily activated and they are easy to engage.

Dr. Barbara Sourkes, a psychologist specializing in the treatment of children facing life-threatening illness, cites the importance of play or fantasy in assisting a child to master his/her experience. "The overwhelming nature of the illness cannot be approached by reality alone” (1995, p. 6). Music therapy offers a child freedom to play, to create and to express.

Play is not only important to a child but serves as a comfort and relief for loved ones. Aasgaard, a music therapist who works in paediatric oncology, notes. “The parent’s stories from the last period of their children's lives often focus on creative acts and play, the child's enjoyment of music, or simply humorous events” (2001, p.180). This parallels my experience in which parents expressed finding particular

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comfort in memories of the moments of joy or pleasure a child experienced during his/her last days. In the midst of demise something of the child was preserved and celebrated. There were shared moments of joy in play, moments of life in the midst of distress.

VOICE OF SPIRIT

Facing issues of life and death propels people to the place of their own spirituality.

People in pain or distress will seek comfort and healing, often accompanied by the search for a sense of meaning. Helen Bonny asserts, "If we work in depth with a person we have to deal with the spiritual aspect of his or her person” (2001, p.61).

There are three spiritual needs a clinician must support: a sense of hope, a sense of meaning and purpose, and interconnectedness with others (Davies et al., 2002).

In my care of the dying I have often reflected on the role of hope near the end of life. I have noticed that although the focus of hope changes shape it is always present for both the parent and child. Hope, then, is integral to life - even as life is ending.

Parents often seek a greater meaning from their painful experience. Melissa’s mom said 'this' has brought the family together…creating a strong bond. “Maybe she's an angel who was sent for a little while", mom mused. Children, thrust into the world of illness develop wisdom beyond their years, seeking meaning from the experience.

Interconnectedness with others is the third important spiritual need. Alliance with significant others including health care professionals, fellow patients, and friends serves to reinforce a child's sense of place and belonging in the world. Children often forge deep bonds with others who are undergoing similar experiences. Interconnectedness is also realized through remembering and gathering. Melissa’s family gathered around her - they talked freely of her loveliness, of what a special child she was, of how everyone was drawn to her. Family and friends from near and far gathered around her bedside. Music from present and past generations filled the air. This gathering and remembering was a necessary preparation for those Melissa would leave behind.

Music supports a deeper connection of spirit. In the world of spirit temporal parameters fall away. Here we enter sacred time and space. Aigen (1998) refers to the sacred world as one, which is “infused with power and an eternal sense of being and reality,” (p. 154). Here time assumes a different order. Eliade describes sacred time as "differentiated, circular and reversible...where the events occurring at cre-

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ation are always recurring” (p. 154). When singing to Gina, through a deeper connection which I choose to call spirit, I was able to give voice to her “flower song” when she was not able to do so.

“Children have an unobstructed relationship with the Infinite” (Dossey, 1996, p.108). Many gifts of this relationship abound in children facing life threatening illness. Laughter, play and humour bubble close to the surface. Simplicity and love remain strong in the most adverse circumstances.

VOICE OF SELF “The psyche or soul of the work is contained in the individuality of each and every therapist “ (Bereznak Kenny, 1989, p. 8).

To be able to enter the world of the other one must have an awareness of oneself. It is my belief that the more deeply a therapist knows herself the more fully she will be available to the client. Examination of the stories, initial dialogue and reflection reveals much about me, my role, my issues and what I bring to the music therapy relationship.

I struggled with my role as music therapist…I was constantly aware of the burden to “prove” music therapy and to “prove” that it can do what other therapies cannot.

This expectation of self can become unrealistic.

There are many ways in which I used my self as well as the voice of my ‘self’ in music therapy. As therapist I am a listener. “The art of listening is ‘central to the human existence’ and necessary in developing meaningful relationships with fellow human beings” (Nichols, 1995, p 16). By the very act of hearing one validates the existence and experience of another. Listening is at the heart of music therapy (Lee, 1996). McMaster describes listening as a sacred act (Bereznak Kenny, 1995, p. 72).

In my experience as a registered nurse and a music therapist I’ve learned to listen to what is beyond the words and behavior in order to get a sense of what is really being expressed.

To enter a child’s world the therapist must be able to play. Sourkes (1995) advises, “The therapist's willingness and ability to enter into play are of utmost importance. Shared imaginative play enables the child to confront the realities of life and death" (p.7).

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Perhaps the most potent aspect of using my ‘self’ is that of bearing witness.

“To witness is not a passive process….In working with a child facing the possibility of death, the therapist must be able to enter the threat with the child...accompany him or her through the steps, while knowing that this may be a journey that they cannot complete together” (Sourkes, 1995, p. 168).

I accompanied Melissa’s family as they walked the final path with their child and bore witness:

• • • • • • • • • • •

to shock and disbelief that her life would end to joy to the searching for a greater meaning to a parent's raw anguish to helplessness to courage to play to sorrow to deep connection to letting go to remembering.

The authentic use of self requires an awareness of transference and counter transference issues which are part of any relationship (Elson, 1986, p. 67) Transference is to be used as a means toward wholeness; however for this to happen the therapist must possess a high degree of self-awareness, be willing to admit mistakes and be able to learn about him/herself without reacting defensively.

I recognize that the exhaustion I have felt is not just because the work is emotionally draining but that the sense of loss, current and anticipatory grief is also being transferred to me from the clients and families. I am aware that my own intense grief for the loss of my own family member will affect me as a therapist. I have a new awareness of cultural counter transference. I know that my responses are based in cultural values often different from those of the patients/families with whom I work. Most cultures have deep beliefs, established rituals around illness, grief, dying and burial.

Buchner suggests that ones story is woven together with the client’s. The children’s stories affect my life and reflect my own truth (Frank, 1995, p.23). That the lives of

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my clients may be woven into my own is a new thought for me. Do I dare to believe this? Am I ready to accept this vulnerability?

In working with critically ill children I am compelled to embrace my own weakness and woundedness - my own 'dyings' so to speak. I am reminded of a prayer, "On each of my dyings shed your light and your love.” (Anon.)

It is not possible to isolate the personal from the professional, but it is imperative that an ever-present awareness exists of the influence of one upon the other. In knowing my own woundedness I find I am able to treat another's with a sense of deep respect, recognizing it is sacred. I am less likely to approach with a sense of “helper” than with a sense of “one who has been helped”. I move with less authority and more a simple “being with”. Working in this way requires taking time to listen to my spirit. It means listening to all of my inner voices so that my “inner place” which opens to the child in therapy, remains uncluttered. I cannot be truly present if I am full of my own stuff.

VOICE OF MUSIC Someday as we are all quiet he sun will stop shining and the world will stop.

All that will be heard Is music.

(Amy, a child in Sourkes, 1995, p. 134)

The place of music in care of the dying is multifaceted.

Music brings comfort. Often children request nursery songs. According to Winnicott, this music from early years serves as a transitional object - a bridge between the child’s inner psyche and his/her recognition of the outer (p. 16). This familiar music was is something a child can hold on to as a form of mother comfort to help withstand the intense emotion of their reality.

Music allows for expression of paradox. Music-making provides children with an opportunity to express conflicting aspects of their realities - fear, anxiety, comfort and love.

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Music‘s capacity to look “beyond the illness to the person” (Pavlicevic, 1997, p.93) creates dignity. Of Melissa I wrote: “It is as if something of the child was preserved and celebrated in the face of demise.” Thus beauty can be known and upheld in a place of loss.

Music reveals self. I have often witnessed that music opens up the child thereby allowing the staff to appreciate him/her in new way.

Music gives courage. Music can give the child courage to look at the things that frighten or cause pain. Music makes it possible to play and to embrace sadness with courage.

Music supports expression of emotion. Grief, rage, regret, hope and resignation are common emotions expressed by families in palliative care. Music is a safe place for a myriad of emotions to be felt, released and communicated (Salmon, 1993).

Music listening gave expression to Saheem’s inner sadness. It offered a place to receive such expression, to acknowledge its truth and to offer an authentic response. Music is a container. It provides a space that provides safety and support (Bereznak Kenny, 1996).

Music is an ally. Saheem’s father wrote,”The music therapy… made the intense chemo (therapy) and side effects bearable”. The music helped Saheem know that he wasn’t alone facing his challenges, helped him bear his difficulties.

Music is caregiver. Sometimes “the therapist's work is far more that of a care-taker; the therapist may have to create music for, rather than with the client (Pavlicevic, 1997, p.151). I created music for Vera and Gina. In this way, the music itself served as caregiver. I have observed that music draws people to a place they need to go, invites them in, offering them the courage to do so. Then it does its restorative, transforming work. Music does all of this with a power and gentleness that is quite beyond that of the therapist who is simply the vessel.

Music is presence. In music therapy, through reflecting the client's music, I am ‘being with’ the client (Pavlicevic, 1997, p. 152). Music creates an intimacy between people. This togetherness is a place that is too deep for words and becomes a healing presence.

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Music’s innate capacity toward organization – to bring order out of disorder makes it well-suited for work with very ill children, whose entire world is disordered.

Music affirms life. By offering Vera and Gina music therapy I agreed that their lives were, indeed, invaluable and that they were worthy of something lovely and beautiful.

Music supports remembering. The music supported a coming together of Melissa’s family for her important passage. Music celebrated the connection with grandma a knowing beyond words. It prompted celebration, mourning, and reminiscence.

SKETCH

And what of the music in the midst of all this dying? Was it of any value? I began with the bass clef in verdant green, a colour of life. Soon, it assumed a dance-like form surrounded by music (yellow tones). At first I thought this depicted my music, but I think it is the music of the child. In the midst of dying, music is a call to life.

It connects with that which is life giving and becomes a rich inner resource.

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FIGURE 4.

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FIGURE 5.

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Discussion This study has been an inquiry into authenticity and integrity in clinical music therapy with very ill or dying children. The research gains credibility because the methodology is appropriate to the purpose of this study. Heuristic methods allow for a careful inward look. Narrative methods support the telling of the story – an effective and appropriate way to describe the clinical work. Phenomenological methods find the essence.

The dependability of my research is insured through repeated reviews of the data at different times and levels. Each story was revisited several times for the purpose of gaining perspective and identifying themes. The themes were carefully coded and categorized. In reviewing data all attempts were made to identify relevant characteristics of the topic under study. The findings were obtained through a consistent analysis of the data. The outcomes presented are my own perspectives. Peer debriefing lends credibility to the research.

By reflecting critically on my own interpretations I employed disciplined subjectivity (Ahonen-Eerikainen, 2003a). Because I am trained in detecting counter transference, the subjectivity was also controlled.

These stories, collected over time, are representative of my experience in general thereby lending transferability to the conclusions. Each story is unique and impossible to replicate in exactly the same way. However it is expected that if six similar stories were analyzed in similar fashion the results would reflect the findings in this study. I believe the findings are useful for other music therapists working in emotionally intense situations.

This study possesses ‘verisimilitude’ which is described as follows: 'When such written accounts contain a high degree of internal coherence, plausibility, and correspondence to what readers recognize from their own experiences and from other realistic and factual texts, they accord the work a sense of 'authenticity' (Atkinson in Denzin & Lincoln, 1998) p. 88.

I have accepted full responsibility for the data and for what I did and did not do with it. The data was not manipulated to reach any conclusions. Throughout this paper I remained true to the data and true to myself, thereby remaining authentic by following Aigen’s premise;

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Discussion

“Authentic is being who I am. It is an at-oneness between consciousness, intentions, experience and action. As a researcher, authenticity is manifested in the kind of research I do, how I focus my efforts, the way I collect and process data, the discoveries I make, and how I communicate them.” (Bruscia, 1996, p. 105).

Aspects of authenticity and integrity are found in the results. By embracing paradox and struggle, one learns to be real; the superfluous falls away. Through embracing life and spirit, one is deeply sustained. Through care of self, one is able to maintain emotional and spiritual health. Music is a gift of offering people a place where something of significance can happen. In music, both the client and the therapist are held and transformed.

This research process has been beneficial on a personal and professional level. I have become more integrated and true to myself in the work. I am embracing the notion of client as healer, with full awareness of counter transference. I am particularly struck with the life, joy and beauty in this work as revealed in the data. It is these aspects of the work that compel and propel one to continue. The stories of children’s lives have served to teach me: to embrace paradox, to struggle, to be fully alive, to live with spirit, to examine myself and to let the music do its work.

The stories have assured me that all things have their place and must be maintained in some form of balance. To ignore any one thing would be to lose the richness. To be ‘sound’ and ‘real’ one must embrace the life-changing experiences offered in this work with courage and humility of spirit.

As I reflect on this process I am left with new wonderings…new questions.

The music itself bears examining…particularly the vocal and instrumental improvisations. An examination of endings in music would inform the music therapist working with people whose lives are ending. I will incorporate music improvisation as part of my self-care in this work, much the way I have begun to incorporate sketching. A deeper orientation toward self-knowledge and self-care may be appropriate in music therapy education so that a therapist may be more fully available to his/her clients. The role of creativity in care of the dying bears inquiry.

"The people who come to us bring their stories. They hope they tell them well enough so that we understand the truth of their lives. They hope we know how to interpret their stories correctly. We have to remember that what we hear is their story" (Buchner, 2001, p. 137).

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It is hoped this paper, has been true to the children in my care in understanding the truth of their lives.

Bibliography Aasgaard, T. (2001). An ecology of love: Aspects of music therapy in the paediatric oncology environment. Journal of Palliative Care, 17 (3), 177-181.

Aasgaard, T. (2002). A suspiciously cheerful lady: A study of a song’s life in the paediatric oncology ward and beyond. British Journal of Music Therapy, 14 (2), 70-82.

Ahonen-Eerikainen, H. (2003, March). The process of doing qualitative music therapy research. Handouts from lecture MU601, Wilfrid Laurier University, Waterloo, ON. Ahonen-Eerikainen, H. (2003, May). Experiential music therapy. Notes from course MU608, Wilfrid Laurier University, Waterloo, ON. Aigen, K. (1996). The role of values in qualitative music therapy research In M. Langenburg, K. Aigen & J. J.Frommer (Eds.), Qualitative music therapy research: Beginning dialogues (pp.10-33). Gilsum, NH: Barcelona Aigen, K. (1998). Creativity in qualitative music therapy research. Journal of Music Therapy,35(3), 150-175.

Amir, D. (1995). On sound, music, listening and music therapy In C. Bereznak Kenny (Ed.), Listening, playing, creating: Essays on the power of sound (pp. 50 – 57). Albany, NY: University of New York Press.

Ansdell, G. (1995). Music for life: Aspects of creative music therapy with adult clients. London: Jessica Kingsley.

Antle, B. et al. (2002, September). Can we ease the burden? A qualitative study of parents’ perceptions of end-of-life care for the children. Paper presented at Hospital for Sick Children, Toronto, ON.

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Armstrong-Dailey A., & Zarbock S. (2001). Hospice care for children (2nd ed.).

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Arnason, C. (2002). Music listening: Giving audience to the music and our clients.

Voices 2 (3), Retrieved November 2002 from http:// www.voice.no Atkinson, P. A. (1990).The ethnographic imagination: Textual constructions of reality. London: Routledge.

Bailey, L. (1984). The use of songs in music therapy with cancer patients and their families. Music Therapy, 4 (1), 5-17.

Barrera, M., Rykov, M., & Doyle, S. ( 2002). The effects of interactive music therapy on hospitalized children with cancer: A pilot study. Psychooncology, 10, 10 – 20.

Bereznak Kenny, C. (1982). The mythic artery. Atascadero, CA: Ridgeview.

Bereznak Kenny, C. (Ed.) (1985). Listening, playing, creating: Essays on the power of sound. Albany, NY: University of New York Press.

Bereznak Kenny, C. (1989). Field of play: A guide for the theory and practice of music therapy. Atascadero, CA: Ridgeview.

Bereznak Kenny, C. (1996). The story of the field of play In M. Langenburg, K. Aigen, & J. Frommer (Eds.) Qualitative music therapy research:Beginning dialogues ( pp.10-33). Gilsum, NH: Barcelona.

Bereznak Kenny, C. (1998). Embracing complexity: The creation of a comprehensive research culture in music therapy. Journal of Music Therapy, 35 (3), 201-217.

Bonny, H. (2001). Music and spirituality. Music Therapy Perspectives, 19, 59-62.

Brodsky, W. (1989). Music therapy as an intervention for children with cancer in isolation rooms. Music Therapy, 8 (1), 17-34.

Bruscia, K. (1996). Authenticity issues in qualitative research In M. Langenberg, K. Aigen& J. Frommer (Eds.), Qualitative music therapy research: Beginning dialogues (pp. 81-107). Gilsum, NH:Barcelona.

Buchner, A. (2001). Narrative’s virtues. Qualitative Inquiry, 7(2), 131-157.

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Coles, R. (1990). The spiritual life of children. Boston, MA: Houghton Mifflin.

Daveson, B. (2001). Music therapy and childhood cancer: Goals, methods, patient choice and control during diagnosis, intensive treatment, transplant and palliative care. Journal of Palliative Care, 17 (3), 114-120.

Daveson, B., & Kennelly, J. (2000). Music therapy in palliative care for hospitalized children and adolescents. Journal of Palliative Care, 16 (1, 35-38.

Davies B., Breener P., Orloff S., Sumner L., & Worden W. (2002). Addressing spirituality in pediatric hospice and palliative care. Journal of Palliative Care, 18(1), 59-67.

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Edwards, J., & Davidson, J. (1998). Music Therapy in anxiety management for children in hospital. Proceedings of the 7th International Music Medicine Symposium & 24th Annual Conference of the Australian Music Therapy Association.

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Gallicchio, D. (1999). Peter and the Wolf: Music therapy and children undergoing chemotherapy. Audiotaped proceedings of the 49th AMTA Annual Conference, Washingon. Walkersville, MA: Satellite Video Production.

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Kearney M, (2002, October 7). The nature of healing: Paper presented at the14th International Congress on the Care of the Terminally Ill. Montreal, PQ. Kuttner, L. (1996). A child in pain: How to help, what to do. New York: Hartley & Marks.

Lane, D. (1996). Music therapy interventions with pediatric oncology patients. In M. Froehlich, (Ed.), Music therapy with hospitalized children: A creative arts child life approach (pp. 109 – 116). Cherry Hill, NJ : Jeffrey Books.

Lee, C. (Ed.) (1995). Lonely waters: Proceedings of the international conference music therapy in palliative care Oxford 1994. Oxford, UK: Sobell.

Lee, C. (1996). Music at the edge: the music therapy experiences of a musician with AIDS. New York: Routledge.

Lee, C. (2003, February). Talks on music and music therapy. Lecture notes from MU602, Wilfrid Laurier University, Waterloo, ON. Liben S., & Goldman, A. (1998). Home care for children with life-threatening illness. Journal of Palliative Care, 14(3), 33-38.

Loewy, J. (Ed.). (1997). Music therapy and pediatric pain. Cherry Hill, NJ: Jeffrey Books.

Magill, L. (2002). Spirituality in music therapy. Music Therapy Today. Retrieved December from http://www.musictherapyworld.net.

Marley, L. (1984). The use of music with hospitalized infants and toddlers: A descriptive study. Journal of Music Therapy, 21(3), 126-132.

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Martin, M. (2001, April). Pediatric palliative care. Video presentation at Humber College Palliative care conference.Toronto, ON. Moffitt, L. (2003, August). Guided imagery in music - level one. Notes from training Course at the Music Therapy Centre, Toronto,ON. Mount, B. (2002, October 7). A physician’s perspective. Paper presented at the14th International Congress on the Care of the Terminally Ill. Montreal, PQ. Moustakas, C. (1990). Heuristic research: Design, methodology and applications.

Newbury Park, CA: Sage.

Muldner. G. (2000). Transforming experience into wisdom: Healing amidst suffering (Forum). Journal of Palliative Care, 16 (2), 25-29.

Munro, S. (1983). Music therapy in palliative /hospice care. St. Louis, MO: MMB Music.

Nichols, M. (1995). Did you hear what I said? The lost art of listening. New York: Guildford Press.

Nye, E. (1997). Writing as healing. Qualitative Inquiry, 3(4), 439-452.

O’Callaghan, C., & Colegrove, V. (1998). Effect of the music therapy introduction when engaging hospitalized cancer patients. Music Therapy Perspectives, 16, 6774.

Palmer, P. (1994). I wish I could hold your hand: A child’s guide to grief and loss.

San Luis Obispo, CA : Impact.

Pavlicevic, M. (1997). Music therapy in context. Philadelphia, PA :Jessica Kingsley.

Pfaff, V., Smith K., & Gowan D. (1989). The effects of music-assisted relaxation on the distress of pediatric cancer patients undergoing bone marrow aspirations. Child HealthCare 18 (4), 232-236.

Polland, B. (1997). Feelings: Inside you and out loud too. Berkeley, CA:Tricycle Press.

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Robb, S. (1999). Piaget, Erikson and coping styles: Implications for music therapy and the hospitalized preschool child. Music Therapy Perspectives, 17, 14-19.

Robb, S. (2000). The effect of therapeutic music interventions on the behaviour of hospitalized children in isolation: Developing a contextual support model of music therapy. Journal of Music Therapy, 37 (2), 118-146.

Roberts, R. (2001, May). Music therapy for children with cancer in acute care.

Paper presented at the28th National Conference of the Canadian Association for Music Therapy, Edmonton, AB. Roberts R. (2002, April). Forum on pediatric palliative care: Who is making a difference? Paperpresented at Humber 12th annual Hospice Palliative Care Conference, Toronto, ON. Roberts, R. (2002, June). Creative care for children:Music therapy in palliative care. Paper presented at the 1st International Conference on Palliative Care, Windsor, ON. Roberts, R. ( 2002, October). Creative care for children at home: A palliative music therapy initiative. Paper presented at the 14th International Congress Care on the Care of theTerminally Ill. Montreal, PQ. Ruud, E. (1997). Music and the quality of life. Nordic Journal of Music Therapy, 6 (2), 86-97.

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Salmon, D. (1993). Music and emotion in palliative care. Journal of Palliative Care, 9 (4), 48-52.

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Standley, J., & Hanser, S. (1995). Music therapy research and applications in pediatric oncology treatment. Journal of Pediatric Oncology Nursing, 12(1), 3-8.

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Turry, A. (1999). The use of clinical improvisation with young children during invasive medical procedure. Audiotaped proceedings of the 49th AMTA Annual Conference, Washington. Satellite Video Production, Walkersville, MA. Vickers, M. (2002). Researchers as storytellers: Writing on the edge - and without a safety net.Qualitative Inquiry, 8(5), 608-621.

Wheeler,B. (Ed.). (1995). Music therapy research: Quantitative and qualitative perspectives. Phoenixville, PA: Barcelona.

Winnicott, C. (1971). Playing and reality. London :Tavistock.

Wolfe, J., Grier, H., & Klar N. (2000). Understanding of prognosis among parents of children who died of cancer: Impact on treatment goals and integrations of palliative care. Journal of American Medical Association, 284, 2469-2475.

Wolfe J., Grier H., & Klar N.(2000). Symptoms and suffering at the end of life in children with cancer. New England Journal of Medicine, 342, 326 -333.

Young, L. (2002, March). Phenomenological research. Notes from course lecture MU601,Wilfrid Laurier University, Waterloo, ON.

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Music Therapy Today, Vol. VI, Issue 4, (November 2005) a publication from MusicTherapyWorld.net

CHAPTER 47

Music therapy training within the European higher education system: A

survey on music therapy training courses in Spain

Sabbatella, Patricia L. Proceedings of the 6th European Music Therapy Congress

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University of Cádiz- Faculty of Sciences Education

1.- TOWARDS THE EUROPEAN HIGHER EDUCATION AREA: THE BOLOGNA PROCESS The construction of a European Higher Education Area (EHEA) by 2010 is one of the most important objectives of the European Ministers of Education to promote the co-operation of higher education institutions within Europe. Within the framework of the Sorbonne Declaration (1998), the Bologna Declaration (1999), the Prague Comuniqué (2001) and the Berlin Comuniqué (2003) different action lines were done in order to achieve the aims of the Bologna Process and the Harmonisation of the architecture of the European Higher Education System. Table 1 shows a summary of the action lines in the construction of the EHEA. TABLE 1.

Summary of the action lines introduced in the construction of the

EHEA DECLARATION SORBONNE 1998

BOLOGNA 1999

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ACTION LINES A progressive convergence of the overall framework of degrees and cycles in an open European Area for Higher Education

• • • • • •

Adoption of a system of easily readable and comparable degrees Adoption of a system essentially based on two cycles Establishment of a system of credits Promotion of mobility Promotion of European co-operation in quality assurance Promotion of the European dimension in higher education

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TABLE 1.

Summary of the action lines introduced in the construction of the

EHEA To emphasised as important elements of the EHEA:

PRAGUE 2001

• lifelong learning • involvement of Higher Education Institutions and students • Promoting the attractiveness of the European Higher Education Area Three intermediate priorities for the next two years:

BERLIN 2003

• • • •

quality assurance, the implementation of the two cycles systems by 2005, and the recognition of degrees and periods of studies.

Doctoral studies and the synergy between the EHEA and ERA

During the Bologna Process new countries were included to the European Higher Education Area. At the moment, the emerging EHEA consists of 40 countries (figure 1).

Norway will host the next Ministerial Conference in May 2005 in Bergen.

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Music therapy training within the European higher education system: A sur-

Countries included on the European Higher Education Area (color-coded geographical areas indicates order of participation) FIGURE 1.

1.1.- ACCION LINES OF THE EUROPEAN HIGHER EDUCATION AREA

1.1.1.- TO ADOPT A SYSTEM OF COMPARABLE DEGREES . One of the most important objectives of the Bologna process is the establishment of readable and comparable degrees. To adopt a system of easily readable and comparable degrees, facilitates transparency in the educational structures and further innovation through communication of experience and identification of good practice. The transparency of qualifications and skills is to be improved through the European Curriculum and providing detailed information on the curricula and their relevance towards a degree, through the implementation of the Diploma Supplement.

As defined in the Bologna Declaration, the study structure of the European Higher Education Area should essentially be characterised by two cycles – undergraduate and graduate:

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1.- TOWARDS THE EUROPEAN HIGHER EDUCATION AREA: THE BOLOGNA

•

UNDERGRADUATE STUDIES (BACHELOR’S DEGREE)

•

GRADUATE STUDIES (MASTER’S AND DOCTORAL DEGREE)

should be professionally oriented, and therefore should provide university training which brings together basic general knowledge, transversal abilities related to the integral training of the student, and knowledge specific to professional orientation which allows degree holders to more easily access the labour market. should be academic, professional and research specialisation in a specific field of scientific, technical, humanistic or artistic knowledge, organised in official postgraduate programs.

1.1.1.1.- DIPLOMA SUPPLEMENT The European Commission, the Council of Europe and UNESCO developed the Diploma Supplement in order to facilitate academic and professional recognition of qualifications (diplomas, degrees, certificates etc.).

The Diploma Supplement is a document attached to a Higher Education Diploma that:

• Provides a standardised description of the nature, level, context, content and status of the studies that were pursued and successfully completed by the graduate.

Information is described in the respective national language and in English language.

• Provides additional information on the National Higher Education System, in order to fit the qualification into the relevant educational context.

• Facilitates international academic and professional recognition of qualifications and improves international transparency .

1.1.2.- TO ADOPT AN EUROPEAN CREDIT TRANSFER SYSTEM (ECTS). ECTS was introduced within the framework of Erasmus programme (1989-1996), now part of the Socrates Programme. It has been tested over a period of 6 years in a pilot scheme involving 145 Higher Education institutions in all EU Member States and EEA countries, and is the only credit system which has been successfully tested and used across Europe.

A Credit System is a systematic way of describing an educational programme by attaching credits to its components. The definition of credits in higher education systems may be based on different parameters, such as student workload, learning outcomes and contact hours.

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ECTS, European Credit Transfer System is a credit system, which provides a way of measuring and comparing learning achievements, and transferring them from one institution to another. As an effective instrument for creating curricular transparency and facilitating academic recognition the ECTS system supports Europeanwide mobility. The system facilitated the recognition of periods of study abroad and thus enhanced the quality and volume of student mobility in Europe.

ECTS is based on the convention that 60 credits measure the workload of a fulltime student during one academic year. The student workload of a full-time study programme in Europe amounts in most cases to 36/40 weeks per year and in those cases one credit stands for 24 to 30 working hours. Workload refers to the notional time an average learner might expect to complete the required learning outcomes.

The allocation of ECTS credits is based on the official length of a study programme cycle. The total workload necessary to obtain a first cycle degree lasting officially three or four years is expressed as 180 or 240 credits.

ECTS makes study programmes easy to read and compare for all students, local and foreign. ECTS facilitates mobility and academic recognition. ECTS helps universities to organise and revise their study programmes. ECTS can be used across a variety of programmes and modes of delivery. ECTS makes European higher education more attractive for students from other continents.

Recently ECTS is developing into an accumulation system to be implemented at institutional, regional, national and European level. (European Credit Transfer and Accumulation System).

1.1.3.- TO PROMOTE EUROPEAN CO-OPERATION IN QUALITY ASSURANCE. A central goal of the “Bologna Process” is to define and observe Europe-wide quality standards in Higher Education. As a response to this Council initiative and the objectives of the Bologna Declaration, the European Network for Quality Assurance in Higher Education (ENQA) was established. Since 1999, ENQA has supplied information about proven practical experiences as well as the newest approaches and discussions in the field of quality assessment and quality assurance.

Accreditation and evaluation are the instruments to realize and observe quality standards. Both serve to assure quality when implementing new degree programmes and also to monitor existing ones. Accreditation, i. e. certification of a degree programme, will take place after review of the minimum standards for content and specialisation, the vocational relevance of the degree to be awarded and the

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1.- TOWARDS THE EUROPEAN HIGHER EDUCATION AREA: THE BOLOGNA

coherence and consistency of the general conception of the degree programme. It will be awarded for a limited period of time within the frame of a transparent, formal and external peer review. Thus, the degree programme has to be reviewed after a certain time. The process of a peer review is steered by agencies which are also reviewed through regular external evaluation.

1.1.4.- TO PROMOTE EUROPEAN DIMENSION IN HIGHER EDUCATION. Within the framework of the EHEA, European Universities should become the most favoured destination for high level learning in the world. Closer co-operation between universities and other higher education institutions which can form so-called “associations” with each other, especially for the organisation of courses at Master’s level in the non-university higher education sector is improved. The activities related to this objective are carried out primarily by the universities themselves either through bilateral or multilateral agreements, or within the framework of more comprehensive programs, such as the EUA Joint Master’s Project.

Researchers from the European university association (EUA) are currently seeking to define a model for European Masters courses. They are addressing issues such as what ‘European’ is to mean in this context, what type of curriculum integration should take place, and what recognition arrangements would be implemented.

The Erasmus Mundus programme is a co-operation and mobility programme in the field of higher education. The programme is intended to strengthen European cooperation and international links in higher education by supporting high-quality European Masters Courses, by enabling students and visiting scholars from around the world to engage in postgraduate study at European universities, as well as by encouraging the outgoing mobility of European students and scholars towards third-countries.

The European Research Area (ERA) shall promote a common use of scientific resources, create jobs on a long-term basis, stimulate competition in Europe and establish synergies with the proposed European Higher Education Area.

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2.- THE SPANISH UNIVERSITY AND THE BOLOGNA PROCESS: CURRENT SITUATION The monitoring, development and coordination of activities in Spain related to the Bologna Process are carried out by the State Secretary for Education and Universities and the Department of Education and Science (Ministerio de Educación y Ciencia), which has set up a committee in which experts and representatives of the institutions involved in the process participate, as well as those ministers responsible for university policies. Inspiration for the implementation of the commitments and policies derived from Bologna Process can be found on the guidelines set out by the Organic Law on Universities on December 21, 2001(Ley Orgánica de Universidades, LOU).

Based on the initial commitments of the Bologna Process and of the legal obligations established by the Organic Law on Universities, a Framework Document was drawn up in February 2003 regarding the Integration of the Spanish University System within the European Higher Education Area (Documento Marco del Ministerio de Educación para la Convergencia Europea en España).

The document includes a catalogue of specific measures to be introduced for the development and implementation of the Bologna Process in Spain and provides for four special fields of action:

• • • •

Degree Structure European Credit System European Degree Supplement Quality Assurance

2.1.- DEGREE STRUCTURE

The Ministerio de Educación y Ciencia has drawn up drafts of the Royal Decrees regarding the structure of university teaching and official level studies, as well as on official post-graduate university studies and the issue of official Master’s and Doctorate degrees:

•

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UNDERGRADUATE STUDIES: Borrador de Proyecto de Real Decreto por el que se

establece la estructura de las enseñanzas universitarias y se regulan los estudios universitarios oficiales de grado. 25 de septiembre de 2003.

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2.- THE SPANISH UNIVERSITY AND THE BOLOGNA PROCESS: CURRENT SIT-

•

GRADUATE STUDIES:

Borrador de Proyecto de Real Decreto por el que se establece la estructura de las enseñanzas universitarias y se regulan los estudios universitarios oficiales de Postgrado. 26 de septiembre de 2003.

The structure of university studies in cycles, provided for in the Organic Law on Universities is based both on a first cycle or level, which should lead to an undergraduate degree, and a second, graduate level, which should lead to a Master’s or Doctorate degree (figure 2).

FIGURE 2.

System YEARS

17 MEDICINE

LONG CYCLE DEGREES

18

Information on the Spanish National Higher Education

19

20

21

22

23

UNIVERSITY (FACULTAD) LICENCIADO UNIVERSITY (FACULTAD)

LICENCIADO LICENCIADO

ENGINEERING DEGREES

24

DOCTOR- PhD 3 - 5 years

UNIVERSITY (FACULTAD, ESCUELA TÉCNICA SUPERIOR) ARQUITECTO / INGENIERO INGENIERO

SHORT CYCLE DEGREES

ARTISTIC EDUCATION

ESCUEL A UNIVERSITARIA / FACULTAD

DIPLOMADO/MAESTRO/ING.TÉCNICO/ARQUITECTO TÉCNICO

MASTER

CONSERVATO RIO SUPERIOR/ESCUEL A SUPERIO R

TITULADO SUPERIOR ESCUEL A SUPERIO R

TITULADO SUPERIOR PROFESSIONAL TRAINING - 2nd CYCLE

CENTRO S DE F ORMACIÓN PROFESIONAL

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TÉCNICO SUPERIOR

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2.2.- EUROPEAN CREDIT SYSTEM: ESTABLISHMENT OF A CREDIT SYSTEM COMPARABLE TO THE EUROPEAN SYSTEM

The credit system was introduced in Spain following the university reform of 1983; credits were determined primarily by the number of teaching hours, including both theory and practice. Additionally, and given the relationship between the ECTS and student mobility programmes, in particular Erasmus, and the important participation of Spanish Universities in this programme, the concept of credits is well known, as well as their usefulness and value for the automatic recognition of scholars in terms of level, quality and relevance.

One of the objectives of the Organic Law on Universities is the adoption of the European Credit System by Spanish Universities. The Royal Decree establishing the use of the European Credit System and the Official Grading System for University Degrees valid throughout national territory, was approved on September 2003 (Real Decreto 1125/2003, de 5 de Septiembre, BOE 224, de 18 de Septiembre de 2003).

The Royal Decree establishes the definition of the European Credit as the unit of assessment of academic activity, including theoretical and practical teaching, as well as other supervised academic activities and the volume of work the student must carry out in order to reach these educational objectives. In Spain institutional grading system according ECTS grading scale is as follows: TABLE 2.

A B C D E F

Spanish grading system according ECTS grading scale

EXCELLENT

10

MATRICULA DE HONOR

VERY GOOD

9

SOBRESALIENTE

GOOD

8-7

NOTABLE

SATISFACTORY

6

APROBADO

SUFICIENT

5

APROBADO

FAIL

4-3-2-1-0

SUSPENSO

According with the Royal Decree establishing the use of the European Credit System and the Official Grading System for University Degrees, in 2003 the General Secretary of Universities and Research (Secretaria General de Universidades e Investigación) of the Secretary of Education and Sciences of the Andalusian Government (Consejería de Educación y Ciencia) in collaboration with the Andalusian

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Committee for the European Higher Education Area (Comisión Andaluza para la implantación del Espacio Europeo de Educación Superior) set up a Pilot Project to introduce the European Credit Transfer System in the Andalusian Universities by academic year 2004-2005.

2.3.- EUROPEAN DEGREE / DIPLOMA SUPPLEMENT

The Royal Decree establishing the implementation of the European Degree Supplement was approved on August 2003, (Real Decreto 1044/2003, de 1 de Agosto, BOE 218, de 11 de Septiembre de 2003), as well as the procedure for its issue by Universities. The regulatory text provides for:

• The issue of the supplement to valid official degrees throughout national terri-

tory (with the exception of diplomas or degrees issued by the Universities themselves or in collaboration with non-university institutions).

• The content of the European degree supplement (student data, degree informa-

tion, information regarding degree level, content and results obtained, the purpose of each degree, additional information, certification of the supplement, and information regarding the national system of higher education).

Information include in the Diploma Supplement is organised in eight sections covering different type of information (table 3).

TABLE 3.

Information included in the Diploma Supplement

DIPLOMA SUPLEMENT: basic INFORMATION 1.- INFORMATION IDENTIFYING THE HOLDER OF THE QUALIFICATION 1.1 Family name (s)) 1.2 Given name (s)) 1.3 (Date of birth)(day/month/year 1.4 Student identification number or code

2- INFORMATION IDENTIFYING THE QUALIFICATION 2.1.- Name of qualification and, if applicable, title conferred (in original language):

• Studies • Title conferred • (state recognised)

2.2.- Main field(s) of study for the qualification) 2.3.- Name and status of awarding institution (in original language): 2.4.- Name and status of institution (if different from 2.3) administering studies (in original language): 2.5.- Language(s) of instruction/examination: Spanish and/or …………………..

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TABLE 3.

Information included in the Diploma Supplement

3. INFORMATION ON THE LEVEL OF THE QUALIFICATION 3.1.- Level of qualification 3.2.- Official length of programme The official length of the programme is….. courses of …. weeks each (……. hours in total) organised as follows: ……… contact hours, devoted to lectures, practical work, specialised seminars, etc. ……… non attendance hours, devoted to student work in his own, The estimate of student work (including the exam and the time It takes the student to prepare them)……

3.3.- Access requirements(s)

4.INFORMATION ON THE CONTENTS AND RESULTS GAINED 4.1.- Mode of study:

• Attendance (lectures, practical work, seminars, etc.)

• Free 4.2 Programme requirements

The programme must complete ..... hours work, which sep the following distribution: ….. Core and compulsory subjects (….. hours) ….. Optional / elective subjects (…. hours) …... Free choice subjects / credits (… hours) 4.3.- Programme details (e.g. modules or units studied) and the individual grade/marks/credits obtained:

• Core and compulsory subjects (subject; contact hours, non-contact hours mark, year, comments)

• Optional / elective subjects (…. hours) • Free choice subjects / credits (… hours) • Subjects taken in other university (Erasmus-Socrates equivalence) 4.4.- Grading scheme and, if available, grade distribution guidance 4.5.- Overall classification of the qualification (in original language):

• Global mark obtained in the degree 5.- INFORMATION ON THE FUNCTION OF THE QUALIFICATION 5.1.- Access to further study

• Access to Advanced Studies Diploma, Doctor Degree, Master and other non-official Postgraduate Studies

5.2.- Professional status (if applicable)

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3.- MUSIC THERAPY TRAINING IN SPAIN WITHIN THE EUROPEAN HIGHER

TABLE 3.

Information included in the Diploma Supplement

6.- ADDITIONAL INFORMATION General information about the University System of the country, the University, etc.

7.- CERTIFICATION OF THE SUPPLEMENT 7.1.- Date 7.2.- Signature 7.3.- Capacity 7.4.- Official stamp or seal

2.4.- QUALITY ASSURANCE

The Organic Law on Universities of 2001 dedicates Section V, to evaluation and certification, establishing as its primary objectives:

• the measurement of public service achievement in university education, • the justification to society of university actions, transparency, comparison,

cooperation and competitiveness of universities in both the domestic and international spheres,

• the improvement of teaching and research activities and of university management, the availability of information to Public Administrations for decision making, and

• availability of information to the general public in order to promote excellence and the mobility of students and teachers.

With the purpose of carrying out the above-mentioned activities the Law provided for the creation of ANECA, the National Evaluation, Certification and Authorisation Agency.

3.- MUSIC THERAPY TRAINING IN SPAIN WITHIN THE EUROPEAN HIGHER EDUCATION SYSTEM: METHOD AND AIMS The purpose of the study is to describe and analyse systematically the present status of Music Therapy at the University in Spain presenting an evaluation of Private and University Masters and Postgraduate Training Programmes of Music Therapy in

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Spain, including information about Music Therapy Optional Subjects offer in undergraduate training programmes in the areas of Health Science (Nursing, Physiotherapy, Logopedics, Occupational Therapy), and Social Science (Special Education Teacher, Musical Education Teacher, Hearing and Language Disability Teacher).

Two matrix of data collection were designed in order to collect and organised information available through Internet search of Web Sites of Spanish Universities, telephone and personal interviews to university teachers and coordinators of Music Therapy University Training Programmes. Curriculum analysis, descriptive analysis and data triangulation with the action lines of Bologna Process are used to analyse, to describe and to discuss information collected.

3.1.- MUSIC THERAPY IN SPAIN: CURRENT SITUATION

Music Therapy in Spain is still a professional activity in the preliminary stages of establishing itself as a discipline and an officially recognised profession. Over the past three decades most initiatives related to Music Therapy have been developed in an informal and non-official manner, in public or private institutions.

During the nineties, there was an increasing interest in Music Therapy both as discipline and as profession. The interest in music therapy training growth and Music Therapy Seminars and Introductory Workshops have been held in Universities (Universidad de Cádiz, Universidad de Barcelona, UNED, Universidad de Valencia, Universidad Jaume I, Universidad Blanquerna), Private Institutes (Centro de Investigación Musicoterapéutica, Música Arte y Proceso) and/or organised by Music Therapy Associations. Simultaneously, different music therapy training programs were offered by Universities and Private Institutes. As consequence of the interest in the field of music therapy and the need to establish a music therapy professional community, many Music Therapy Associations were founded in Spain in the latest nineties and in the beginning of the XXI Century.

Nowadays there is a growing demand of music therapist for the fields of Special Education, Geriatric Music Therapy, Neurological rehabilitation, Psychiatric and Medical Music Therapy. Although there are a lot of interest about music therapy as profession and in music therapy training, nowadays Music Therapy in Spain is not recognised as a profession by the government, neither as an official university degree1.

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3.- MUSIC THERAPY TRAINING IN SPAIN WITHIN THE EUROPEAN HIGHER

3.2.- MUSIC THERAPY AT THE UNIVERSITY: AN OVERVIEW

There are sixty-nine Universities in Spain (Public and Private). The structure of university studies in cycles, provided for in the Organic Law on Universities, is based both on a first cycle or level, which should lead to an undergraduate degree, and a second, graduate level, which should lead to a Master’s or Doctorate degree.

University studies in Spain may be grouped into five branches: Humanities; Experimental Science, Health Science; Social and Legal Science; and Technical Education. Each branch may comprise, according to the case, first cycle; first and second cycle; second cycle only; and third cycle doctoral education.

During the nineties, the interest in music therapy training growth and Music Therapy Seminars, Workshops and Music Therapy training programs have been held different Universities. The present status of Music Therapy at the University in Spain includes:

• Postgraduate Music Therapy Training Programs offered by Public or Private Universities

• Music Therapy Optional / Elective Subjects offered within official undergraduate universities degrees

• Introductory courses, Summer courses, seminars and workshops There are not Doctoral Programmes in Music Therapy (PhD) in Spain.

3.2.1.- MUSIC THERAPY TRAINING PROGRAMMES. In Spain Music Therapy Training Programmes, - at Master or Post-Graduate Level-, are offered both by Private Institutions (since 1986) and Universities (since 1992).

From and historical perspective, the first Postgraduate Training Course in Music Therapy were offered by private institutions (Centro de Investigación Musicoterapéutica de Bilbao y en la Escuela de Musicoterapia y Técnicas Grupales de Vitoria-Gasteiz) during the eighties. In 1992, the first University Music Therapy Program was offered at the University of Barcelona and led by Serafina Poch.

During the nineties different Music Therapy Programs were organised both in private and public universities with different level (postgraduate /master) (table 4)

1. An extended report about Music Therapy in Spain was offered by the author in an article recently published (Sabbatella, 2004).

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.

TABLE 4.

Music Therapy Training Courses in Spain (May, 2004)

MUSIC THERAPY TRAINING COURSES IN SPAIN PUBLIC UNIVERSITIES

PRIVATE UNIVERSITIES

PRIVATE INSTITUTES

Universidad Autónoma de Madrid

Universidad Católica de San Antonio

Centro de Investigación Musicoterapeútica

Universidad de Barcelona

Universidad Pontificia de Salamanca

Instituto Música, Arte y Proceso

Universidad de Cádiz

Universidad Ramon Llull

Musitando

Universidad Nacional de Educación a Distancia

Fundación Mayeusis ISEP ICSE

According with the category and number of institutions that offer Music Therapy training courses in Spain Information collected shows that :

• Four Public Universities offered Music Therapy Training at Postgraduate or Master Level

• Three Private Universities offered Music Therapy Training at Postgraduate or Master Level

• Six Private Institutions offered Music Therapy Training In order to describe the current situation of Music Therapy training at University level, a matrix for data collection was designed covering a wide range of information in different areas:

• • • • • • •

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Name of the University Level of Qualification of the Music Therapy Studies offered Starting Date of Programmes Recognition Entry requirements Official length of the Programme Curriculum /Programme

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3.- MUSIC THERAPY TRAINING IN SPAIN WITHIN THE EUROPEAN HIGHER

• Training programme coordinator (professional standing) • Number of Music Therapists involved on the training – Guest teachers • Areas of Clinical work Data collected are presented in table 5.

TABLE 5. MATRIX FOR DATA COLLECTION

MATRIX FOR DATA COLLECTION

UNIVERSITY

AUTÓNOMA DE MADRID (Public University, Madrid)

QUALIFICATI ON

lenght

CURRICULU M

COORDI NATOR

Nº M T 3

Postgraduate

2 years

Music

University

Curso Superior de Formación en MT

1025 hours

Music Education

Teacher

102 cr.

Music Therapy

(Psychology)

Music Psychology

Consultant MT

(2000)

MT in Education Psychiatric MT Medical MT

Practicum Thesis Postgraduate

2 years

Music

University

Curso de Postgrado

504 hours

Music Psychology

Teacher

50 cr.

Health Sciences BARCELONA (Public University, Barcelona)

areas of clinical work

Master

Music Therapy

Master en MT

Practicum (6 m.)

(1992/2001)

6

MT in Education

(Medicine)

Psychiatric MT

Consultant MT

MT in physical rehabilitation

Medical MT

Geriatric MT

Thesis

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TABLE 5. MATRIX FOR DATA COLLECTION

Postgraduate

2 years

Music

University

Curso de Experto Universitario en MT

550 hours

Music Education

Teacher

55 cr.

Music Psychology

Master Master Universitario en MT

Music Therapy

(2000)

Practicum (3 m.)

PONTIFICIA DE SALAMANCA (Private University, Salamanca)

1395

MT in Education

(MusicMT)

Psychiatric MT Medical MT MT in Neurological rehabilitation

Health Sciences

CÁDIZ (Public University, Cádiz)

CATÓLICA DE SAN ANTONIO (Private University, Murcia)

8

Geriatric MT

Supervision Thesis Postgraduate

2 years

Music

University

Curso de Especialista Universitario en MT

430 hours

Body Movement

Teacher

43 cr.

Music Therapy

(2003)

Psychology Practicum

3

MT in Education Psychiatric MT

(Medicine)

MT in rehabilitation

Consultant MT

Thesis Postgraduate

2 years

Music

University

Especialista Universitario en MT

970 hours

Music Education

Teacher

97 cr.

Music Therapy

Master

Psychology

Master Universitario en MT

Supervision

(2001)

(MusicMT)

Practicum Thesis

June 16-20, 2004 University of Jyväskylä , Finland

4

Focus on education but introductory to other areas

3.- MUSIC THERAPY TRAINING IN SPAIN WITHIN THE EUROPEAN HIGHER

TABLE 5. MATRIX FOR DATA COLLECTION

UNIVERSIDA D NACIONAL DE EDUCACIÓN A DISTANCIA (Public University, Madrid)

Postgraduate

One year

Curso de Formación del Profesorado: Música y Salud: Introducción a la MT

University

150 hours

Music Education

15 cr.

Health Sciences

(Music Education -MT)

Music Therapy Practicum

Focus on education

4

Medical MT

Teacher

Thesis

(1996) Postgraduate

2 years

Music

University

Especialista Universitario en MT

600 hours

Music Education

Teacher

60 cr.

Master RAMON LLULL (Private University, Barcelona)

1

Master Universitario en MT (1996)

Music Psychology

(PsychologyMT)

MT in Education Psychiatric MT Geriatric MT

Music Therapy Clinical Work Practicum Thesis

3.2.1.1.- MUSIC THERAPY TRAINING PROGRAMMES: RESULTS A.- LEVEL OF QUALIFICATION OF MUSIC THERAPY STUDIES OFFERED Four Universities offer Double Music Therapy Degrees, both at Postgraduate and Master Level (Barcelona, Cádiz, Pontificia de Salamanca, Ramon Llul):

•

POSTGRADUATE LEVEL,

•

MASTER LEVEL

for students with a short degree: Diplomatura in the branches of Health Science (Nursing, Physiotherapy, Speech Therapy, Occupational Therapy), Social Science (Special Education Teacher, Music Education Teacher, Hearing and Language Disabilities Teacher), or , for students with a long degree (Bachelor in the branches of Health Science (Medicine, Psychology), Humanities (History, Musicology), Art (Music, Dance).

Three Universities offer a Degree at Postgraduate Level, for students with a short degree (Autónoma de Madrid, Católica de San Antonio, UNED): Diplomatura in the branches of Health Science (Nursing, Physiotherapy, Speech Therapy, Occupational Therapy), Social Science (Special Education Teacher, Music Education

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Teacher, Hearing and Language Disabilities Teacher). Students with a long degree (Bachelor) are also accepted.

B.- STARTING DATE OF PROGRAMMES The first University that started a training programme in Music Therapy was the University of Barcelona in 1992. This university stopped the programme and it was offered, in 1996 at the private University Ramon Lull. During year 2000 and 2001 different public and private universities started to offer Music Therapy studies (see table 5).

C.- RECOGNITION Music Therapy Training, at Postgraduate or Master level, are recognised as own Degrees offered by each University (Título Propio). According with the structure of University Studies in cycles provided by the Organic Law on Universities and the Bologna Process, Music Therapy studies in Spain are not official degrees included in the annual catalogue of Graduate Studies offered for Spanish Universities.

D.- ENTRY REQUIREMENTS The general requirement to apply to University Music Therapy studies in Spain is usually the completion of an undergraduate degree at bachelor level (short or long bachelor degree Diplomatura-Licenciatura), or equivalent in the fields of Music, Education, Health Science, Social Science, Humanities and/or Art. There are not unified criteria to assess students entry requirements. Most courses selected students on the basis of an interview and audition. Applicants for the studies have to pass an exam of musical skills and music performance, and to demonstrate personal qualities needed for music therapy practice. The assessment of these skills is made through personal interview, musical skills are tested using different assessment tools.

Most of the courses required English proficiency to the level of reading comprehension.

E.- OFICIAL LENGTH OF THE PROGRAMME The training programmes cover two years of training, with a period of music therapy practicum, except for the training programme at the UNED (one year). Teach-

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ing hours, including both therapy and practice, range from 150 hours (UNED) to 1025 hours (Aut贸noma de Madrid).

Music Therapy training programmes offers teaching hours in Spanish credit system (10 hours of class-work = 1 credit), but this system is not equivalent with the European Credit Transfer System (ECTS). According to this the structure and length of the Music Therapist training programmes in Spain must be adapted in the future.

F.- CURRICULUM /PROGRAMMAE There is a significant variety with regard to the architecture of Music Therapy training courses in Spain. The seven University training courses analysed are different in structure, duration, academic level and theoretical orientation. Although there is a dominant trend and it is possible to distinguish common objectives, tasks and areas of study among them, there are not unified criteria to define the core areas of study, subjects, skills and competences to become a professionally-qualified music therapy.

Curriculum analysis shows that programmes have common AREAS OF STUDY among them: Music, Music Therapy Theory, Clinical Practice (Health Sciences), Music Therapy Practicum and Supervision. These common areas of study covers different subjects, contents, number of contact and practical hours and didactic and experiential training in how music and the client-therapist relationship are used to promote health. There are large differences both in length and depth of study.

About OBJECTIVES, the programmes are designed to give students the ability to apply music therapy theory to practice on a broad range of clinical populations, theoretical orientations, practices and methods.

THEORETICAL ORIENTATION of the training programs do not concentrate on any single model or method, are eclectic. Music Therapy programmes in Spain give a wide picture of music therapy, its different schools, models and methods. The orientation of the studies are focus on the professional practice of Music Therapy as a primary objective of the programmes (not focus on research).

EXPERIENTIAL COMPONENTS of the programme are designed to sensitise students to the effects of the music on the therapy process and the self-experience of the music therapy process on the student. Another important element is focus on give the students opportunities to explore and refine his/her own individual philosophy and style of working.

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MUSIC THERAPY PRACTICUM (clinical field experiences) are an integral part of the music therapy curriculum. There are not too much music therapists working in Spain, so in some cities is not easy to find enough institutions to provide a wide range of clinical practicum options for students in the programmes.

G.- TRAINING PROGRAMME COORDINATOR (PROFESSIONAL STANDING) The Spanish University System establish that Postgraduate and Masters Programmes must be coordinated by university teacher staff.

From a total of seven Music Therapy University training programmes only four are coordinated by university staff with training in the field of music therapy (UNED; Universidad Ramon Lull, Universidad Pontifícia de Salamanca, Universidad de Cadiz).

The other three programmes are coordinated by university staff of related fields (psychology and medicine) that have an external consultant in the field of music therapy who acts as programme’s coordinator (Universidad Autónoma de Madrid, Universidad de Barcelona, Universidad Católica de Murcia).

H.- NUMBER OF MUSIC THERAPISTS INVOLVED IN THE TRAINING – GUEST TEACHERS The number of professionally-qualified music therapist involved in University training is diverse, and depends on the curriculum organisation of each university.

The academic background of the music therapists working and teaching in Spain is diverse: some of them are Music therapists with a University Degree or a Postgraduate Training at Master Level in Music Therapy obtained at a foreign university (Latin-America or USA); but most of them are professionals of other disciplines with a Postgraduate Training in Music Therapy obtained at Private Institutes during the nineties (instituto Musica, Arte y Proceso, Centro de Investigación en Musicoterapia de Bilbao).

Some training courses have foreign teachers (Universidad de Cádiz, Universidad Ramon Llul) and most of them invite teacher from other Spanish universities or institutes to teach (Universidad de Cadiz, Barcelona, Pontificia de Salamanca, Católica de San Antonio, Ramon Llul).

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Only five qualified-music therapists who have a PhD are involved in teaching music therapy at the University in Spain.

I.- AREAS OF CLINICAL WORK University Music Therapy programmes are designed to give students the ability to apply music therapy on a broad range of clinical populations.

The client populations covered in training courses tended to be similar, in the fields of Music Therapy in Education, Psychiatric Music Therapy, Medical Music Therapy; Music Therapy in physical and neurological rehabilitation and Geriatric Music Therapy. Two of these courses (UNED and Pontificia de Salamanca) are more focus on Music Therapy in Education but introduce clinical practice in other areas.

Usually students choose one are of clinical work and client population for music therapy practicum 3.2.2.- MUSIC THERAPY OPTIONAL/ELECTIVE SUBJECTS OFERED IN UNDERGRADUTE UNIVERSITIES DEGREES

Within the official studies recognized by the Spanish Government, Music Therapy is offered as a subject in different Universities Degrees. The positive point is that Music Therapy is included as a subject in different degrees and allows its promotion within the students of related professions to Music Therapy.

In order to describe the current situation of Music Therapy training at University level, a matrix for data collection was designed covering a wide range of information in different areas:

• • • •

University – Faculty – Department Degree Subject - Credits Teacher Staff

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Data collected are presented in table 6.

Optional subjects offered at University undergraduate studies in Spain during academic year 2003-2004 TABLE 6.

UNIVERSIT Y

FACULTY

DEPARTMENT

DEGREE

SUBJECT

CR.

ALCALA DE HENARES

E. U. Cardenal Cisneros (College)

Expresión Musical, Plástica y Corporal

Hearing and Language Disabilities Teacher

Music Therapy

4.5

AUTONOMA DE MADRID

E. U. Lasalle (College)

Expresión Musical, Plástica y Corporal

Special Education Teacher

Music Therapy

4.5

Special Education Teacher

Music Therapy workshop for pupils with special needs education

4.5

Teacher Training Expresión Musical, Plástica y Corporal BURGOS

Humanity and Education

Expresión Musical, Plástica y Corporal

Musical Education Teacher

Fundamentos de Musicoterapia

5

CÁDIZ

Sciences Education

Didáctica de la Educación Física, Plástica y Musical

Musical Education Teacher

Music Therapy in Music Education

4.5

Music Therapy in Hearing and Language Disabilities

4.5

Hearing and Language Disabilities Teacher Special Education Teacher

CORDOBA

1401

Sciences Education

Didáctica de la Expresión Musical, Plástica y Corporal

Music Therapy in Special Education

4.5

Musical Education Teacher

Music Therapy

6

Special Education Teacher

Music Therapy

6

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3.- MUSIC THERAPY TRAINING IN SPAIN WITHIN THE EUROPEAN HIGHER

Optional subjects offered at University undergraduate studies in Spain during academic year 2003-2004 TABLE 6.

GRANADA

HUELVA

Sciences Education

Sciences Education

Musical Education Teacher

Music Therapy

4.5

Special Education Teacher

Music Therapy

4.5

Expresiรณn Musical, Plรกstica y Corporal

Musical Education Teacher

Music Therapy

4.5

Psychology

Special Education Teacher

Music Therapy

4.5

Expresiรณn Musical, Plรกstica y Corporal

JAUME I

Sciences Education

Expresiรณn Musical, Plรกstica y Corporal

Musical Education Teacher

Introduction to Music Therapy

4.5

LA CORUร A

Health Science

Psychology

Occupational Therapy

Music Therapy

4.5

LA RIOJA

Education

Expresiรณn Musical, Plรกstica y Corporal

Special Education Teacher

Music Therapy

4.5

LEON

Education

Expresiรณn Musical, Plรกstica, Corporal, Dibujo y Educaciรณn Fรญsica y Deportiva

Musical Education Teacher

Music Therapy

6

Special Education Teacher

Music Therapy

6

Expresiรณn Musical, Plรกstica y Corporal

Musical Education Teacher

Music Therapy

6

Special Education Teacher

Music Therapy

6

MALAGA

Sciences Education

MURCIA

Education

Expresiรณn Musical, Plรกstica y Corporal

Musical Education Teacher

Music Therapy

4.5

SEVILLA

Sciences Education

Expresiรณn Musical, Plรกstica y Corporal

Special Education Teacher

Music Therapy

4.5

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Optional subjects offered at University undergraduate studies in Spain during academic year 2003-2004 TABLE 6.

PONTIFICIA DE SALAMANCA PAIS VASCO

Sciences Education

Education

Special Education Teacher

Music Therapy

E.U. Magisterio (Education College)

Didáctica de la Expresión Musical, Plástica y Corporal

Special Education Teacher

Music Therapy

4.5

Special Education Teacher

Music Therapy

4.5

Musical Education Teacher

Music Therapy

4.5

Physiotherapist

Music Therapy

E. U. Magisterio (Education College) VALENCIA E.U. Fisioterapia Physiotherapy

Didáctica de la Expresión Musical, Plástica y Corporal

4.5

4.5

From a total of 69 public and private universities, 17 offer Music Therapy subjects within undergraduate studies.

Two universities offer Music Therapy subjects at the Health Sciences College, Universidad de La Coruña, offering a subject in the degree of Occupational Therapy, and Universidad de Valencia, offering a Music Therapy subject in the degree of Physiotherapy.

The rest of the universities, 15, offer Music Therapy subjects at the Faculties of Education, within the degrees of Teacher Education, in the fields of Special Education Teacher and Musical Education Teacher. From 15 universities, 2, offer Music Therapy subject in the degree of Hearing and Language Disabilities Teacher (Alcalá de Henares and Cadiz) Departments involved in the teaching are those related to Music and Music Education subject fields (Departamento de Expresión Musical, Plástica y Corporal). Only in the case of Universidad de La Coruña, the Department of Psychology is involved on music therapy teaching.

The subjects offer are generally called Music Therapy, in some cases the name of the subject vary according the degree where it is offered (eg. Music Therapy in Special Education, Music Therapy in Music Education, Music Therapy in Hearing and Language Disabilities).

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4.- CONCLUSION

The subjects offer are optional subjects covering 45-60 hours of teaching (4.5-6 Spanish credit system), display on one semester.

About qualification of the teacher staff involved not all of them are qualified-music therapists with clinical experience in music therapy. Most of them are teachers of the field of music or music education that attended introductory training course or summer course in music therapy. Only a few of them attend International, European and Latin American Music Therapy Congresses. About publications, some of them published some articles but on the general field of Music Therapy in Education, or Music Therapy History, not regarding clinical practice, theory or research of Music Therapy.

Data collection revealed that there are optional subjects offered related to the field of music therapy but not named as Music Therapy, for example:

• Music for students with learning disabilities: Universidad de Almeria • Music in Special Education: Universidad de Granada • Music for students with Special Needs Education: Universidad de Granada (Melilla)

• Music for handicapped children: Universidad de Málaga

4.- CONCLUSION The main conclusion of the study is that there is a significant variety with regard to the architecture of Music Therapy training courses offered by Universities in Spain.

The seven University training courses analysed are different in structure, duration, academic level and theoretical orientation. There are large differences both in length and depth of study.

Although there is a dominant trend in the curriculum and it is possible to distinguish common objectives, tasks and areas of study among them, there are not unified criteria to define the core areas of study, subjects, skills and competences to become a professionally-qualified music therapy.

According with the structure of University Studies in cycles provided by the Organic Law on Universities and the Bologna Process, Music Therapy studies in

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Music therapy training within the European higher education system: A sur-

Spain are not official degrees included in the annual catalogue of Graduate Studies offered for Spanish Universities. Music Therapy at Postgraduate or Master level are recognised as own Degrees offered by each University (Título Propio). This situation promotes that too many private institutions offer short training courses in music therapy (100 hours) with not qualified music therapy teachers.

As Music Therapy training programmes are not official degrees its difficult to connect teaching and exchange of students with Erasmus-Socrates programme. Cooperation is only used for teacher mobility at the University of Cádiz and University Ramon Lull.

Music Therapy training programmes offers teaching hours in Spanish credit system. According with the Royal Decree establishing the use of the European Credit System and the Official Grading System for University Degrees, in 2003, the structure and length of the Music Therapist training programmes in Spain must be adapted in the future to ECTS system.

To establish unified criteria and standards for Music Therapy training that leads to an official Master in Music Therapy according the rules of EHEA requires the establishment of the syllabus according the action lines of the Bologna Process and the guidelines set out by the Organic Law on Universities (Ley Orgánica de Universidades, LOU):

• To adapt the architecture of the studies in order to unified the curriculum and

delimitate core subjects and contents presenting the coursework of studies in European Credits Transfer System (ECTS) with the structure of an official Master Diploma (120ECTS).

• To establish an unified set of learning outcomes and competences for Music

Therapy studies in order to implement the Diploma Supplement (although the Spanish University does not give diploma supplement for non official master).

• To prepare university and official documents for government recognition and

national accreditation of the Spanish foreign agency ANECA (Agencia Nacional de Evaluación y Calidad Educativa), compulsory for official degrees/masters in Spain.

According the Bologna Process and the current status of Music Therapy Universities studies at Master or Postgraduate Level in Spain, music therapy studies will not be officially recognized by the government according the standards of the EHEA. A deep modification is needed in order to get it.

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4.- CONCLUSION

The insertion of the National University System in the Bologna Process is clearly an attractive element of Spanish centres in all Graduate and Postgraduate Degrees.

A new perspective is coming in order to bring a Europe-wide convergence in Higher Education. Further internationalisation of universities and intensification of mobility will guarantee a wide access to university education and an increase in the quality of study offers. Within the perspective of the Erasmus Mundus Programme, the overseas promotion of the Spanish university system within the framework of the European Higher education Area will, over the next few years, be considered a field for special pursuits in national policies on university cooperation with third countries and intensified university relations within the framework of the UEALC (European Union – Latin America – Caribbean Programme).

4.1.- IMPLICATIONS FOR MUSIC THERAPY TRAINING PROGRAMMES WITHIN THE EUROPEAN HIGHER EDUCATION AREA

The context of the Bologna-Prague-Berlin process has provoked an intense debate on the nature of educational structures, the role and the social dimension of Higher Education and the structure of the University Degrees in Europe.

There has been too much discussion in Europe about the potential for establishing a common standard for music therapy education. This has proven very difficult, given the wide variation in the length of the training courses – from a one year postgraduate study to five –year full-time studies- and the variation in the contents of the courses (Wigram, De Backer & Van Camp, 1999).

One of the most important objectives of the Bologna process is the establishment of readable and comparable degrees and the adoption of a two cycle system. The construction of an European Higher Education Area (EHEA) by 2010 could be an attractive element for Music Therapy studies in Europe in order to obtain official recognition of Music Therapy studies in the European Community2.

Music Therapy training courses in Europe need to integrate themselves within the rules of the EHEA and define a model for European Masters courses in Music Therapy, with curriculum convergence and a set of professional competences that facilitate European and national government recognition. This proposal implies:

• To develop professional profiles and desired learning outcomes and compe-

tences in terms of generic competences and subject-related competences includ-

2. The European Music Therapy Confederation is working on it.

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ing skills, knowledge and content to become a professionally-qualified music therapy.

• To develop and exchange information in relation to the development of curric-

ula in the selected areas, and develop a model of curriculum structure expressed in ECTS.

Within the framework of the EHEA, European Universities should become the most favoured destination for high level learning in the world. Closer co-operation between universities, through International Programmes as Socrates–Erasmus or Erasmus Mundus could enhance the quality of Music Therapy Training and Research and to promote intercultural understanding through co-operation with third-countries.

The European University System is in a period of change that could be described as historical. It is time that Music Therapy can reach the academic and professional status that is deserved. A great work is needed to get it.

5.- REFERENCES AND LINKS Bologna Declaration of the European Ministers of Education (1999). The European Higher Education Area:http://www.bologna-berlin2003.de/pdf/ bologna_declaration.pdf Del Campo, P. (1993). Music Therapy in Spain. In C. Dileo-Maranto, Music Therapy: International Perspectives. Pennsylvania: Jeffrey Books.

Documento Marco del Ministerio de Educación, Cultura y Deporte. La Integración del Sistema Universitario Español en el Espacio Europeo de Enseñanza Superior.

10 de febrero de 2003. http://wwwn.mec.es/univ/html/informes/EEES_2003/ Documento_Marco.pdf Documento Marco del Ministerio de Educación, Cultura y Deporte. Borrador de Proyecto de Real Decreto por el que se establece la estructura de las enseñanzas universitarias y se regulan los estudios universitarios oficiales de grado. 25 de septiembre de 2003. http://wwwn.mec.es/univ/html/informes/EEES_2003/ Borrador_RD_estudios_grado.pdf

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5.- REFERENCES AND LINKS

Documento Marco del Ministerio de Educación, Cultura y Deporte. Borrador de Proyecto de Real Decreto por el que se establece la estructura de las enseñanzas universitarias y se regulan los estudios universitarios oficiales de Postgrado. 26 de septiembre de 2003. http://wwwn.mec.es/univ/html/informes/EEES_2003/ Borrador_RD_estudios_postgrado.pdf Erdonmez, D. (1996). Directory of Music Therapy Training Courses: World-Wide.

World Federation of Music Therapy.

European Music Therapy Confederation (2003). European Music Therapy Confederation: Spain. [online]. Retrieved February 9, 2004, from http://www.musictherapyworld.net/modules/emtc/spain/emtclist.php Lorenzo, A. (2004). La Formación en Musicoterapia. Experiencias a nivel universitario. Primer Congreso Internacional de Verano: Desarrollos en Musicoterapia.

Lago Castro, P. (2004). La formación permanente del profesorado en Musicoterapia con metodología a distancia. Primer Congreso Internacional de Verano: Desarrollos en Musicoterapia Poch, P. (1993). Music Therapy in Spain. In C. Dileo-Maranto, Music Therapy: International Perspectives. Pennsylvania: Jeffrey Books.

Poch, S. (1999). Compendio de Musicoterapia Volumen I - II. Barcelona: Herder.

Real Decreto 1044/2003, de 1 de Agosto, por el que se establece el procedimiento para la expedición por las Universidades del Suplemento Europeo al Título. BOE núm. 218, de 11 de Septiembre de 2003. http://www.boe.es/boe/dias/2003-09-11/ pdfs/A33848-33853.pdf Real Decreto 1125/2003, de 5 de Septiembre, por el que se establece el Sistema Europeo de Créditos y el Sistema de Calificaciones en las Titulaciones Universitarias de carácter oficial y validez en todo el territorio nacional. BOE núm. 224, de 18 de Septiembre de 2003. http://www.boe.es/boe/dias/2003-09-18/pdfs/A3435534356.pdf Sabbatella, P. (1999). Músico-Terapia: ¿Moda o Realidad?. Tavira, 19, 95-103.

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Sabbatella, P. (2000). Musicoterapia: Profesión de Futuro CD-ROM XX Cursos de Verano de San Roque: Seminario Música y Medicina, 1-7. UCA-Ayuntamiento de San Roque.

Sabbatella, P. (2003). La Evaluación en la Práctica Profesional de la Musicoterapia: Un Estudio Descriptivo en el Contexto Iberoamericano. Tesis Doctoral. Universidad de Cádiz.

Sabbatella, P. (2004). Music Therapy in Spain. Voices: A World Forum for Music Therapy. Retrieved March 31, 2004, from http://www.voices.no/country/ monthspain_march2004.html Spain: National Report. European Conference of Ministers of Higher Education.

Berlin, September 2003. http://www.bologna-berlin2003.de/ Terán, D. (2000). Un Apunte para la Historia de la Musicoterapia en España.

Música, Terapia y Comunicación, 20, 121-125.

Wigram, T; De Backer, J. & Van Camp, J. (1999). Music Therapy Training: A process to develop the musical and therapeutic identity of the music therapist. In T. Wigram & J. De Backer (ed), Clinical Applications of Music Therapy in Developmental Disability, Paediatrics and Neurology. London: Jessica Kingsley Publishers.

LINKS

Acreditation: http://www.accreditation-council.de/ Diploma supplement: europa.eu.int/comm/education/policies/rec_qual/recognition/diploma_en.html Implementation of the Diploma supplement: www.cepes.ro/hed/recogn/groups/diploma/Default.htm European Centre for Higher Education: www.cepes.ro/ European Research Area: europa.eu.int/comm/research/era/index_en.html European Credit Transfer System: http://europa.eu.int/comm/education/bruges/ index_en.html

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Author

European University Association (EUA): www.eua.be/eua/ European Association of Institutions in Higher Education: www.eurashe.be/ European Network for Quality Assurance in Higher Education (ENQA): http:// www.enqa.net/ ERASMUS: Thematic Network Projects: http://europe.eu.int/comm/education/ socrates/tnp/index.html International Network for Quality Assurance Agencies in Higher Education (INQAAHE): http://www.inqaahe.nl/ Lifelong Learning: http://europa.eu.int/comm/education/index_en.html Network of Universities from the Capitals of Europe (UNICA): www.ulb.ac.be/ unica/ Programa de Convergencia Europea: www.aneca.es/modal_eval/prog_conver.htm Recognition of Diplomas in the European Union: europa.eu.int/comm/education/policies/rec_qual/recognition/in_en.html The Europe of knowledge 2020. A vision for university based-research and innovation. Liege, 25-28 April, 2004. http://europa.eu.int/comm/research/conferences/ 2004/univ/results_en.html Tuning Project: http://odur.let.rug.nl/TuningProject/index.htm; www.relint.deusto.es/TUNINGProject/index.htm

Author Dra. Patricia L. Sabbatella Universidad de Cádiz - Facultad de Ciencias de la Educación - Área de Música República Saharahui s/n. Apartado 34

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11519 - Puerto Real - Cádiz - España Tel: + 34-956-016225 Fax: + 34-956-016253 E-mail: patricia.sabbatella@uca.es

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Music Therapy Today, Vol. VI, Issue 4, (November 2005) a publication from MusicTherapyWorld.net

CHAPTER 48

The effectiveness of music therapy approach focused on ‘subjective tempo’

Saji, Nobuko & Sugai, Kuniaki Editors note: Check for the html version with all video and audio files on MusicTherapyToday.com (November 2005)

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Abstract In this study, we confirmed that people with severe senile dementia, the disease of irreversible deterioration, still possess ability to learn, and the approaches focused on subjective tempo and the continuous music therapy sessions could enable them to learn new songs. Subjective tempo, first defined by Perilli in 1993, is the tempo in which each individual can respond spontaneously to music, such as singing, playing drums, clapping hands or performing in other ways.

For approximately 4 years, we examined 70 subjects (the mean ages: 82.74±1.19 years, the mean MMSE:14.6±5.7), who were clients in our weekly music therapy group sessions and individual sessions. In every session, first, we identified the subjective tempo of each subjects through his/her responses to a well-known familiar song, then played an unfamiliar song to each individuals with their just identified subjective tempo and observed the process of learning this particular song.

The results demonstrated that 1) severely demented clients have potential to learn a new song, although more time was required than slightly demented clients, and that 2) the approach using subjective tempo is effective to support and maintain learning ability of elderly people with dementia.

1. Introduction 1.1. MUSIC THERAPY RESEARCH TO DEMENTED CLIENTS

The latest findings from medical science, using noninvasive examinations of brainfunction such as MRI and CT scan, have shown that performing cognitive tasks such as numerical calculation or reading out loud can have an effect on the cognitive abilities of the elderly people. These visually measurable examinations indicate that the above behaviors, especially reading out and singing would activate the frontal and back channels of brain map(Kawashima 2002).

Since 1998, we have held group and individual sessions for people suffering from senile dementia in Japan and examined the efficacy of music therapy practice through physiological and behavioral evaluations (Saji, Sugai & Saji, 2004a). Previously, we have reported the first physiological evaluations of our research in the 10th world congress of music therapy at Oxford (Saji, Ueno & Sugai, 2002, in press) and the International Musicological Congress at Shizuoka (Saji, Sugai & Ueno, 2004b). These reports demonstrated that severely demented subjects showed significant differences at the alpha-2 bands only on right channels while they lis-

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1. Introduction

tened to familiar songs (<.05) and familiar songs played with subjective tempo (<.01).We considered familiar songs and subjective tempo produced a big active change in the EEGs of severely demented subjects. EEG analysis of non-severely demented subjects also showed significant differences in the theta-1 and theta-2 bands on the right and left channels while they listened to familiar songs (<.05) and familiar songs played with subjective tempo(<.05) and non-subjective tempo(<.05).

We considered that non-severely demented subjects had ability to adjust themselves to familiar songs played with both subjective tempo and non-subjective tempo, so their EEGs showed active changes in the right and left channels. Therefore music therapy sessions with subjective tempo are effective for subjects with dementia, particularly for those with severe dementia, and we also confirmed that EEG analysis is useful to assess the efficacy of music therapy for subjects suffering from dementia (Saji, Sugai & Ueno, 2004b).

Many music therapy researches (Aldridge 2000, Brotons 1996, Clair 1991 and 1996, Clair & Berstein 1990a and 1990b, Hanser 1990 and others) based on behavioral evaluation of people with Alzheimer’s disease have pointed out that “musical functions may be retained longer than speech functions” (Aldridge, 1996) and that “music therapy is a viable approach to promote meaningful and purposeful activities even into the last stages of dementias” (Hanser & Clair 1995, p. 346). While we examined the processes of acquisition and deterioration of musical skills of demented clients in the nursing home, we also found they had potential to learn a new song. Sugai (1994) hypothesized that the learning process of human linguistic ability was linked to the information system of the human brain. He examined the process through the early phonetic and linguistic behavior of children with developmental delays, examining their behavior when they sang popular Japanese nursery songs. His process of the early development of speech behavior was from auditory and visual to tactile reception Today, we will present the second behavioral evaluation from the same research focused on ‘subjective tempo’. Examining this process in which demented clients acquired music is important in informing treatment to support improvement in clients’ quality of life.

1.2. THE TEMPO IN MUSIC THERAPY

We found the ‘tempo’ is extremely important to communicate with demented clients in music therapy sessions, particularly with those who are severely demented.

Since we first began working at a nursing home for elderly people with dementia, including Alzheimer’ disease, cerebral infarction, Parkinson’s disease and others, we were interested in reactions of clients to music. When familiar music was

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played, every client immediately made relaxed expressions and released tension from their bodies. Soon, they began to show responses to the music. Some of them moved their mouths, some of them tapped their hands in time with the music, and others nodded slowly. However, very few of them showed different reactions. They either became agitated and frustrated or made no responses as if they heard nothing.

In such cases, we assumed that there was a gap between the tempo we played and their subjective tempo. In another words, we understood that the tempo of the given music was beyond the capacity of which they could understand and make responses to. On the other hand, we understood that for those who showed musical responses, the tempo of the music was closely matched with their subjective tempo. In this way, we assumed that the receivable tempo could be a crucial factor, which allowed the clients to make musical responses.

1.3. GROUP SESSIONS

Japanese elderly people generally enjoy singing and playing familiar music together in groups but show strong resistance to sing or play alone. Maybe it is because they are very shy and feel embarrassed to perform in front of someone.

However, playing together seems to bring joy to them and enables them to relax.

Aldridge stated group music therapy was “generally used to expand socialization and communication skills, with the intention of reducing problems of social isolation and withdrawal, to encourage clients to interact purposefully with others, assist in expressing and communicating feelings and ideas, and to stimulate cognitive processes, thereby sharpening problem-solving skills ” (Aldridge 1996, p.195). In our group sessions, however, there were some clients who need special support in a group session. Some of them were in the severe stages of their illness and their subjective tempos were remarkably slower than others. Some of them wandered around during the whole session and could not sit together with others. Then our individual sessions were started for them.

1.4. WHAT IS ‘SUBJECTIVE TEMPO’?

The term ‘Subjective Tempo’, first stated by Perilli in 1995, however, has also been called in other ways. In 1933, psychologist Frischeisen-Koehler used the term ‘personal tempo’ and, in 1951, Mischima, who was also a psychologist, used the term ‘mental tempo. Both psychologists examined the subjective tempo from natural spontaneous finger tapping of healthy students. Stern (1985) and Fraisse (1982) also talk about ‘spontaneous tempo’. Based on this ‘spontaneous tempo’, Perilli assumed that subjective tempo might change or vary between people and also within each person, according to emotional and pathological states. She examined each tempo of natural spontaneous finger tapping of healthy students and adults with mental illness. From this research, Perilli concluded that the tempo of which

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2. Methods

individuals spontaneously tapped are directly connected with their psychomotor, cognitive and emotional processes. In other words, this subjective tempo is the speed in which each individual could apprehend, register and understand incoming stimuli. Also, the subjective tempo is the speed in which each individual could react, plan and perform behavioral responses to stimuli (Perilli 1995, p.104).

1.5. THE DEFINITION OF ‘SUBJECTIVE TEMPO’

We thought, however, the examination by finger tapping would not be suitable for clients with dementia because they had difficulties in understanding and following the instructions and also had poor physical functions. Therefore, we carefully examined the overall responses of every participant during the sessions and searched for each individual subjective tempo, the tempo that elicits smile or allows either spontaneous drum beating, hand clapping or singing. Through these observable responses, we concluded that it is the subjective tempo that enabled elderly people with dementia to listen, to understand, and to express themselves spontaneously. At the same time, these reactions indicate that the interpersonal communication had been formed between the clients and the therapist, who is the performer of the music. However, the identification of subjective tempo was done through observation and they were determined by the therapist’s experience.

The purpose of this study is to examine the effectiveness of music therapy approach focusing on subjective tempo to elderly people with dementia.

2. Methods 2.1. DEMENTED CLIENTS

During 4 years of this research, 70 people (mean age: 82.74±1.19, mean MMSE:14.6±5.7), participated in our weekly music therapy group sessions and individual sessions. We classified these clients into two groups: The severely demented group, the group of those who were less than MMSE 8, and the nonseverely demented group, the group of those with MMSE 11 to 23. Table 1 shows the attributes of the clients in severely and non-severely demented groups (mean ± standard deviation).

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TABLE 1.

Severe group and non-severe group (2001)

Groups

Numbers

Mean Age

Mean MMSE

Severe

36(12/24)

84.06•}7.54

5•}3.27

Non-severe

34(9/25)

81.62•}8.90

19.47•}5.39

2.2. SUBJECTIVE TEMPO

In every session, we identified and recorded the subjective tempo of each client through his/her response to the well-known familiar songs and examined each client’s behavioral change, which occurred over the four years.

In this research, we understood that when clients responded spontaneously to given music, it indicated that subjective tempo was closely connected with client’s current conditions. The therapist made a judgment whether the music was played in suitable tempo or not, through clients’ behaviors. If they responded to the given music by singing or tapping hands and other positive behaviors, the therapist considered that they could understand the music and respond to it. On the other hand, if they began to speak something unrelated to the song, stand up and walk around, fall asleep or perform other passive behaviors, as if they heard nothing, the therapist considered that they could not understand the music and respond to it. Beside these, the therapist found the middle responses. Some of them seemed to be willing to respond to the music, but could not figure out how to respond. Even if the clients did not make any responses, or even if the therapist could not recognize any intension of making responses to the music from their behavior, it was important for the therapist to keep the musical contact with them. The therapist hoped and waited for them to respond spontaneously.

We reported previously that the mean subjective tempo of a familiar working song, ‘Saitaro-bushi’, in non-severely demented group rose above M.M. =80, but in severely demented group, the mean subjective tempo was kept under M.M. =80 (Saji & Muzuno, 2003). This study examined mainly subjective tempo of children’s songs or old Japanese school songs.

2.3. THE LEARNING SONG: THE UNFAMILIAR SONG

For the unfamiliar music, we chose a pop music kind of song, called ‘Present My Love’. This song was composed specially for this nursing home in 1998. So it was new for every body and truly an un-familiar music for clients. The words of the song expressed appreciation to nature and life and it was very touching for elderly

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2. Methods

people, but the melody was complicated with many phrases with up beats, syncopations and jumping tones and others. The tempo was indicated in M.M. =108 by the composer, but of course it was too fast for the all demented clients. We thought the song was unsuitable for music therapy sessions, but the director of this nursing home strongly requested us to play this song in the sessions. Reluctantly, from May 1998, we started to play it at the end of every session as an ending song. While the song was played, clients returned to their own rooms. We did not expect them to sing or play with this music, but only hoped that, one day, all the staffs and residents would become familiar to this song and be able to sing together on ceremonies.

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FIGURE 1.

Score of the new unfamiliar song, 'Present My Love'

Notes: This song is a new styled music. For examples 'a' in the score indicates the phrase beginning with up- beat, 'b' indicates syncopation rhythm and 'c'

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3. Results

2.4. THE STANDARD EVALUATION OF A LEARNING SONG

Unexpectedly, soon after we began to play this unfamiliar song, ‘Present My Love’, some clients requested for a score. Therefore, we thought that this song could be a good material to observe the process of learning of a new song. We played this song for approximately 4 years at the end of every session and observed the process of changes occurred in responses of each member. We classified them into three stages.

The first stage: The stage of Negative responses; this is the stage when clients showed no responses to music, or began to speak something unrelated to the song, or when he/she fell asleep. The second stage: The stage of Non-negative responses; this is the stage when the clients showed little reactions, such as looking at other members singing or the therapist. The third stage: The stage of Positive responses.

We subdivided this stage into two levels: when the clients moved mouths or heads with the music, we identified as they are in the first level. When the clients sang the song loudly or sang from the beginning to the end of the song, we identified as they are in the second level.

3. Results 3.1. RECORDED SUBJECTIVE TEMPOS

Subjective tempos of every individual were video recorded from 1998 to 2001.

Before we played the new unfamiliar song, ‘Present My Love’ as an ending song, we played the familiar children’s songs and old Japanese songs and identified the subjective tempos of each member from their singing, nodding head, tapping hands and others. Figure 1 shows the mean subjective tempos of their responses to the familiar songs in both severely demented group and non-severely demented group.

The mean subjective tempo of non-severely demented group was faster than that of severely demented group. Particularly in ‘Yuhyake-koyake’ (a children’s song), ‘Kono-michi’ and ‘Sakura-sakura’ (old Japanese songs) the mean subjective tempos of non-severely demented group were clearly different from those of severely demented group. Other songs in Figure 1 showed close or same subjective tempos.

Mean subjective tempo of ‘Yuhyake-koyake’ (a children’s song) and ‘Kono-michi ‘(an old Japanese song) was under M.M. =60 in severely and non-severely

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demented groups. On the other hand, mean subjective tempo of other songs were among M.M. 6080 similarly in both groups FIGURE 2.

M.M. =

80

Mean subjective tempo recorded in music therapy sessions

severe group

non-severe group

70

60

50

40 Yuhyake- Furusato Nanatsukoyake no-ko

Koujyono-tsuki

Konomichi

Sakura- Yurikago- Teruterusakura no-uta bozu

‘Severe group’ indicates severely demented group and ‘non-severe group’ indicates non-severely demented group. ‘MM =’ indicates M.M. (Metronome Marking) equals.

3.2. LEARNING PROCESS OF A NEW UNFAMILIAR SONG.

Every session, the new unfamiliar song, ‘Present My Love’ was played with the subjective tempo, which was identified from familiar songs. I have noted the mean subjective tempo we played in each stage. The tempo of non-severely demented group on each stage was faster than those of severely demented group. For instance the tempo of the non-severely demented group in Positive response level I and II was M.M. =66-72. However, the tempo of the severely demented group in Positive response level I and II was M.M. =63-69.

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3. Results

Figure 2 shows the difference in learning process between the severely and non-

Severe group

Non-severe group Start 1998 May

Negative response

Negative response

With Score 1998 Nov.

Non-negative response

Positive response ,h

M.M. =69-72

M.M. =66-69

1999 Feb.

M.M.

=72-76

Non-negative response

1999 June

M.M.

=72

Positive response ,h

1999 Nov.

M.M.

=69-72

2000 Nov

M.M.

=66-69

Positive response ,h,h

2001 Apr.

M.M.

=66-69

Half of group could sing

M.M.

=66

Most of group could sing

With Text 2000 May

Positive response ,h,h

M.M. =63-66

2001 June

Half of group could sing

M.M. =63

2002 Jan. 2002 Mar. Finish

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The effectiveness of music therapy approach focused on ‘subjective tempo’

severely demented groups of ‘Present My Love’. It took approximately three years for the severely demented clients to reach the Positive responses stage.

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3. Results

FIGURE 3.

LLearning process of the new song, ‘Present my love’

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The effectiveness of music therapy approach focused on ‘subjective tempo’

Severe group’ indicates severely demented group and ‘non-severe group’ indicates-

non-severely demented group. ‘ ‘ =’ indicates M.M. (Metronome Marking) equals.

4. Discussion 4.1. REGARDING ‘SUBJECTIVE TEMPO’ IN MUSIC THERAPY PRACTICE

As above-mentioned, from our studies the mean subjective tempo of a familiar working song, ‘Saitaro-bushi’, was above M.M. =80 in non-severe demented group, but in severely demented group, the mean subjective tempo was under M.M. =80 (Saji et al. 2003). From Figure 1, however, the mean subjective tempos of familiar children’s songs and old Japanese songs in both groups were under M.M. =80. Perhaps, because these familiar songs might be in client’s childhood memory, and many clients seemed to call them to their mind, while they played together with the song. Therefore it is generally considered that these children’s songs and old Japanese songs will become slower and be suitable for the last songs on calming down sessions.

Though the subjective tempo of ‘Yuhyake-kotake’, ‘Kono-michi’ was under M.M. =60 and suitable for the last closing songs, we considered them not to be suitable for the songs before the last song, ‘Present My Love’. Because the tempos under M.M. =60 would be in reminiscences for demented groups, in particular severely demented group. Therefore, in order to allow the demented people to learn new songs, we concluded that the song should be played with the subjective tempos of familiar songs within M.M. 60-80. Then the clients will join and play the song without strain.

4.2. REGARDING MUSIC THERAPY FOCUSED ON SUBJECTIVE TEMPO

Figure 2 showed that the tempo of non-severely demented group on the each stage was faster than those of severely demented group. When the half of the severely demented group were able to sing, the tempo of ‘Present My Love’, was M.M. =63 and when the half of the non-severely demented group were able to sing together, the tempo of ‘Present My Love’, was M.M. =66-69. From this longitudinal research on ‘subjective tempo’, we found each client had a different subjective

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4. Discussion

tempo according to his/her condition. The subjective tempo of each individual changes subtly and sensitively from session to session. Therefore from continuous recordings of subjective tempo, we could get hold of the current physical condition of the clients and the progress and the degree of deterioration of their illness.

Also we considered that music therapy focused on subjective tempo led the clients to relax and to take an active part in musical performance, which also allowed them to experience interpersonal communication. Although half of the severely demented group members remained unable to sing or hum the melody of the new song, they did show that they had ability to sense the rhythm of the song, by nodding their heads or tapping their hands with the song. In these ways, some parts of learning ability of every client seemed to have recovered during this research. It was useful to use the subjective tempo of familiar songs in order to introduce and allow clients to learn unfamiliar song. This may indicate that music therapy focusing on subjective tempo do have a great possibility for cerebral revitalization.

TABLE 2.

The learning period of each stage

Positive II

Response

Negative

Non-negative

Positive I

Severe group

13 months

11 months

13 months

7 months

Non-severe group

9 months

4 montha

17 months

5 months

Half of clients Most of clients 9 months

Notes: Participants' responses were classified into three stages of Negative response, Non-negative response, Positive response I and II. In Table 2, severe group indicates severely demented group and non-severe group indicates non-severely demented group. Half or Most of group indicate that the half or most of the group could sing the song. Months show the period spent in each stage.

Table 2 showed there was difference in learning process of â&#x20AC;&#x2DC;Present My Loveâ&#x20AC;&#x2122; between the two groups. Non-severely group reached each stage earlier than severely demented group except for Positive responses level I. This research may suggest that the severely demented group is capable of learning a new song, if the song was played to them continuously and in their subjective tempo.

However, we still need more investigations and further researches to confirm the effectiveness of the music therapy approach focused on subjective tempo.

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5. Conclusion The evidences obtained were as followed: 5.1. The Most of non-demented clients have potential to learn a new unfamiliar song, and the half of severely demented clients will be able to sing or listen to it.

5.2. It suggests the approach using subjective tempo is effective to support and maintain learning ability of elderly people with dementia

Acknowledgment We are grateful to our patients for showing us that they still posses many potentials.

We also pay special appreciation to the nursing home for elderly people with dementia in Miyagi, and to Doctor Takashi Ueno, who is a professor of University of Tohoku, for their cooperation. Lastly, I would like to add that this study was supported by the Division for Promotion of Health and Medical Care for the Elderly, Ministry of Health and Welfare, and Miyagi University.

Reference Aldridge, David (1996). Music therapy research and practice in medicine. From out of the silence. London: Jessica Kingsley Publishers, 186-209.

Aldridge, David (2000). Music therapy in dementia care: more new voice. London: Jessica Kingsley Publishers, 9-62.

Brotons, Melissa E., & Pickett-Cooper, Patricia. (1996). The effect of music therapy intervention on agitation behaviours of Alzheimer’s disease clients. Journal of Music Therapy, 33, (1), 2-18.

Clair, Alicia A. (1991). Music therapy for a severely regressed person with a probable diagnosis of Alzheimer’s disease. Bruscia, Kenneth E. (Ed) Case studies in music therapy. Gilsum, NH: Barcelona Publishers, 571-580

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Reference

Clair, Alicia A. (1996). Therapeutic uses of music for older adults. Baltimore, MD: Health Professions Press, 61-90.

Clair, Alicia A., & Bernstein, Barry. (1990a). A preliminary study of music therapy programming for severely regressed persons with Alzheimer’s-type dementia.

Journal of Applied Gerontology 9(3), 299-311.

Clair, Alicia A., & Bernstein, Barry. (1990b). A comparison of singing vibrotactile and non-vibrotactile instrumental playing responses in severely regressed persons with dementia of the Alzheimer’s type. Journal of Music Therapy, 27, 119-125.

Fraisse, Paul (1982) Rhythm and tempos. In Deutsch, Diana (Ed.), Psychology of music. New York: Academic Press, (pp.149-180).

Frischeisen-Koehler, I (1933). Festsellung des weder langsamen noch schnellen (mittelmaessigen) Tempos. Psychologische Forschung, 18, 291-298.

Hanser, Suzanne B. (1990). A music therapy strategy for depressed older adults in the community. Journal of Applied Gerontology, 9, 283-298.

Hanser, Suzanne B., & Clair, Alicia A. (1995). Retrieving the losses of Alzheimer’s disease for clients and care-givers with the aid of music; In Wigram, Tony, Saperston, Bruce & West, Robert (Eds.) The Art & Science of Music Therapy (pp.342360), HAP. Kawashima, Ryuta. (2002). Functional Plain Imaging Neuropsychology Collections. Tokyo: Igakushoin.

Mishima, Jiro (1951). Fundamental research on the constancy of “mental tempo”.

Japanese Journal of Psychology, 22(1), 12-27.

Perilli, Gabriella G. (1995). Subjective tempos in adults with and without Psychiatric Disorders. Music therapy perspectives, 13(2), 104-109.

Saji, N., Sugai K., Ueno T. & Saji, R. (2002). Subjective Tempos on Music Therapy for Persons with Senile Dementia. The 10th World Congress of music Therapy, Abstract book, 206.

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The effectiveness of music therapy approach focused on ‘subjective tempo’

Saji, N., & Mizuno, Y. (2003). Qualitative research of the efficacy of music therapy for older adults with dementia based on three-year examination of ‘subjective tempo’ and EEG. 2003 The reports of health care research for elderly people with dementia, 90-101.

Saji, Nobuko, Sugai, Kuniaki, & Saji, Ryoya (2003). Evaluating the efficacy of music therapy for elderly people with dementia, based on a three-year examination of ‘subjective tempo’, Japanese Journal of Music Therapy, 3(1), 46-53.

Saji, Nobuko & Ueno, Takashi (2004a). Behavioral and EEG Analysis of the efficacy of music therapy for an elderly person suffering from Parkinson’s disease and dysarthria. The Annual Report of Department of Education, Tohoku University, 52, 377-389.

Saji, Nobuko, Sugai, Kuniaki, & Ueno, Takashi (2004b). Assessment by EEG analysis of music therapy for persons with senile dementia, International Congress Reports of Musicological Society of Japan.

Saj, N., Sugai K., Ueno T. & Saj, R. (in press). Subjective Tempos on Music Therapy for Persons with Senile Dementia. Reports of The 10th World Congress, Oxford, UK. Stern, Daniel N. (1985). The Interpersonal World of the Infant. New York: Basic Books, 249.

Sugai, Kuniaki (1994). A new evaluation method of early speech behavior. Using a Japanese playing song, ‘Genkotsu-yama-no-tanukisan’. The Annual Report of Department of Education, Tohoku University, 42, 97-131.

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Music Therapy Today, Vol. VI, Issue 4, (November 2005) a publication from MusicTherapyWorld.net

CHAPTER 49

Maintaining dialogue - active music therapy for people living with Multiple Sclerosis

Schmid, Wolfgang University Witten/Herdecke, Institute for Music Therapy

Proceedings of the 6th European Music Therapy Congress

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Introduction Dear colleagues, in my talk „Maintaining Dialogue-Active Music Therapy for People living with Multiple Sclerosis“ I will present you some of my practical work from the controlled study „Active Music Therapy for people living with Multiple Sclerosis“, which I did last year in a team consisting of a doctor, a nurse, a statistician and under supervision of David Aldridge.

I start with a video-episode out of this project.

It shows the therapeutic situation as it is representative for my work with patient and therapist improvising music.

In this episode we both play on congas. The patient knows the instrument and he plays it in a characteristic way, without pauses and with many changes in his rhythmic ideas. He seems to be very concentrated on his own playing and the coordination of his hands. In fact he has a medium ataxia in his arms with problems to coordinate them.

I accompany him in different modes: first I try to follow him, then I start to use pauses and play more impulsive rolls on my drum. This attracts his attention to me as a fellow musician and his playing changes.

FIGURE 1.

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Episode “becoming playful”

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Background

As you could hear and see, there were different levels of contact and interaction in this episode.

In my qualitative analysis of all music therapy sessions I identified the individual interaction and contact between patient and therapist as the core-construct for the therapy-course and most important for the changes in therapy.

I will come back later to this idea, and continue now with some informations about MS, as well as the needs of the patients for complementary and alternative therapies.

Then I will present you the findings of my study, showing some quantitative results and the results of my qualitative evaluation, illustrating them with some video-episodes out of the project.

Background Multiple Sclerosis is the most frequent inflammatory disease of the central nervous system among young adults. There is an estimated number of 2,5 million people with MS worldwide.

A major fact, patients and therapists are confronted with is, that MS is a degenerative disease and there is no cure.

MS causes a variety of symptoms and complex constellations of symptoms, which can affect each area of human life. Main symptoms are fatigue (a special kind of tiredness), sensory, motor and speech problems.

The origins of the disease have been intensively researched in the last decade and it became possible to influence the progress of the disease with medication to some degree.

While medical approaches undoubetly focus on a functional strategy for treatment, we cannot ignore that diseases like MS have also implications for the performance and appearance of a person in everyday life.

As there are no curative treatments, we are reliant on medical as well as on palliative interventions and rehabilitation.

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The frequently life-long process of coping, that begins with the diagnosis of MS, requires continous efforts to adapt to changing situations and obviously demands a range of therapies which must also consider and encourage a patient´s creative abilities.

According to recent publications, MS-patients are expressing increasing interest in alternative and complementary therapies.

One reason for this is that the patients want to play a more active role in coping with the disease. Another reason is the demand for a wider range of therapies to meet social and emotional needs and for mental health in general.

In my research for literature I found five studies about music therapy with MSpatients (Alcock, 2001; Magee, 2002; Rothwell, 1997; Schmidt, 1998; Springer, 2001; Wiens, 1999).

Four with qualitative, one with a quantitative design.

They all have clinical, but different backgrounds and show the benefits of music therapy in giving patients a chance to become active, to become creative, and supporting them in their coping process by singing and composing songs.

Only the quantitatve study from Wiens et al. (1999) has a controlled design, showing that a special programme with singing and breathing improves the respiratory muscle strenght in patients with advanced multiple sclerosis.

THE STUDY

In my controlled study twenty patients (14 female, 6 male) with MS were involved.

Their ages ranged from 29 to 47 years, and with an average disease duration of 11 years.

Ten participants formed the therapy group and ten the control group.

The groups included patients with minimal disability signs as well as patients with disability impairing full daily activities.

The therapy group got three blocks of 8-10 individual sessions of active music therapy (Nordoff/Robbins approach)over the course of one year.

Exclusion criteria were pregnancy and mental disorders requiring medication.

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Method

The protection of data privacy and the ethical aspects were examined and approved by the Ethic Committee of the University of Witten/Herdecke.

AIMS

The main questions for the study were: what kind of specific support MS-patients can gain from Active Music Therapy and which changes can be discovered in standardised interviews.

Method FIGURE 2.

Flexible design

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Maintaining dialogue - active music therapy for people living with Multiple

Therefore we implemented a flexible design for the study, collecting qualitative and quantitative data. This data consisted of video episodes from the music therapy sessions. And a music therapy interview, asking participants about their experiences with music therapy.

Both groups were interviewed with a neuropsychological test battery and psychological interviews before therapy began and at three months intervals.

Results FIGURE 3.

I continue with the quantitative results of the standardised interviews and tests: at the start of the study and at the final assessment stage one year later there were no significant differences between the music therapy group and the control group.But improvements were found for the therapy group over time in the scale values of self-acceptance, depression and anxiety. This improvements can be compared as effect sizes (shown here: dark blue: therapy-group; light blue: control-

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Results

group). Here we see a considerable effect between the beginning and the end of the therapy on improving self-esteem and relieving depression and anxiety for the people of the music therapy group. Only minimal improvements were found in the subscale „communication“ of the quality of life scale.In both groups there were no recognizable changes in motor and functional abilities.

So we could say, that the form of Creative music therapy used here is valuable for promoting a positive self identity and relieving the emotional burden on a patient.Other music therapy approaches may focus different subjects.

I´d like to show you two results in detail.

FIGURE 4.

Self - acceptance (SESA)

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The scale of self-acceptance shows a significant effect for the therapy group in selfacceptance, which is comparable to the normal population (the control group is shown in blue, music therapy group is shown in orange).

FIGURE 5.

Subscale anxiety (HADS-A)

Significant differences were found for the therapy group and for the control group in the subscale anxiety of the HADS, while the values of the control for depression and self-acceptance did not show any differences over time.

This may be an indication that being recruited for a trial and being regularly assessed is perhaps in itself an important intervention for this group.

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Results

I continue with my qualitative evaluation.

I selected 37 video-episodes from the 226 sessions, showing characteristic situations of therapeutic change, which I found in a process of analysing (that means looking at and listening to them) and in discussions with my supervisor David Aldridge. The episodes were evaluated by Kellys Repertory Grid Method and the Therapeutic Narrative Analysis, finding categories for what happens in music therapy.

A main result, the main categorie and core-construct of the qualitative evaluation is the individual contact between MS- patient and therapist in music therapy.

9 PARAMETERS FOR CONTACT IN MUSIC THERAPY

To describe this contact more in detail, I found 9 sub-categories, I call them parameters for contact in music therapy. These parameters are.:

• „attitude of patient and therapist towards therapeutic situation“, that is e.g. do we play or do we exercise and work in music therapy ?

• • • •

„the idea for joint music making“, e.g. a melodic motif, a mental image. „The question if we improvise or play or sing a composed piece of music „the material for music making: e.g the choice of instrument or the voice“ „the musical roles of patient and therapist“ (this is e.g.the question who leads and who follows?).

• „the ability to structure time“ • „the ability to initiate changes in play“ • For this we have „the dynamic elements of music“ and the ninth parameter

• „movement“ which represents all signs of non-verbal body-language: is there bodily movement or not, is there eye-contact or not.

When I start to describe an episode in terms of this parameters for contact, I see that it is not only one parameter per episode, but two or more parameters that are connected with each other.

In the next episode with he title „thinking about music“ the parameters „attitude towards the situation“, the clearness of the „musical roles“ and the „temporal strucure“ are important for the contact, they are connected with each other and can be used to explain the interaction.

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The episode shows the beginning of our playing: the patient has decided to play four drums in the same sequence. You hear what happens, when I try to follow his idea tone for tone, and what happens, when a clear Metrum and Tempo are intoduced into the music.

FIGURE 6.

Episode “thinking about music”

This episode as well as the others show, that parameters for contact are connected with each other and occur together in groups. This groups have dynamic qualities depending on how they are related to each other in various situations. Although I found no hierarchy in the parameter system, I can fix three groups of parameters.

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Results

FIGURE 7.

Basis parameters for contact - 1

There are the three basis-parameters: „attitude towards therapeutic situation“, the „idea for joint music making“ and the „material“. Basis-parameters stand for conscious or unconscious descisions of patient and therapist for the joint music making. They are a kind of frame for the music therapy sessions. As all parameters their properties can change and lead to another quality of contact.

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FIGURE 8.

Basis parameters for contact - 2

Beside the basis-parameters there are three interaction-parameters.

1.

2.

3.

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First is „movement“ which stands for all aspects of non-verbal communication like body-movements, gesture or mimic.

Second is the „musical roles“: I found that it is very important in music therapy with MS-patients, to help them to find a clear musical role, as we have it in a song for example. : singer and accompanist.

The third interaction-parameter is „temporal structure“, which means, that the ability to structure time gives both players or singers a reliable temporal ground for their interaction.

June 16-20, 2004 University of Jyväskylä , Finland

Results

FIGURE 9.

Basis parameters for contact - 2

Last but not least there are two alteration-parameters, which stand for changes in music like ritardando or accelerando but also for changes in style or mood of music.

PHASES OF CONTACT

This three groups of parameters follow each other and can be described as phases for contact in active music therapy with MS-patients.

1.

2.

First phase is „exploration“: where patient and therapist become active. Within his activity the patient can orientate himself.

The second phase is „interaction“: here a bodily experience comes into music; the patient integrates his body-movements into his musical expression. His body-expressions become part of the encounter.

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3.

The third phase is „development“: in which the expressive repertoire of both, patient and therapist, develops and both find in a new balance.

This three groups of parameters follow each other and can be described as phases for contact in active music therapy with MS-patients.

1.

2.

3.

First phase is „exploration“: where patient and therapist become active. Within his activity the patient can orientate himself.

The second phase is „interaction“: here a bodily experience comes into music; the patient integrates his body-movements into his musical expression. His body-expressions become part of the encounter.

The third phase is „development“: in which the expressive repertoire of both, patient and therapist, develops and both find in a new balance.

I would like to play some more episodes to you, focussing the second phase of contact „Interaction“ with coordination and bodily experience in music therapy interaction.

I found that active joint music makong supports patients bodily experience as well as the expressive repertoire of their bodies.

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Results

FIGURE 10.

This happens in many individual ways and is shown in the parameter grafik. „Movement“ can be supported by

• MATERIAL: Instruments which have sounding qualities like gongs, the steeldrum etc. in contrast to rhythmic instruments

• singing songs as well as improvising • MUSICAL ROLES and TEMPORAL STRUCTURE: By playing in an alternating, dialogic mode, which challenges both players

• A moving instrument, as it can be seen in the next episode.

In the episode „moving instrument“ the patient is interested in the sound and movements of the ‚ocean drum‘. She says that the instrument makes movements she can-

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Maintaining dialogue - active music therapy for people living with Multiple

not do any more. I play with her, but also just listen to her playing. The epsiode is an example for how a patient needs time to come into contact with her own playing.

FIGURE 11.

Episode “moving instrument”.

The episode „singing“ is from the patient you saw before with the conga. He sings freely and brave for his first time in therapy. With his voice as „material“, he is independent from motor functioning and establishes a slow and flexible tempo with rubatos. The music is enlivened by growing tension and relaxation. He seems to enjoy it and there is room for emotional expression and sense of tone in the music.

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Results

FIGURE 12.

Episode â&#x20AC;&#x153;singingâ&#x20AC;?

For some patients it is not as naturally to sing. One idea was, to combine body movements and singing.

This can be seen in the next episode.The patient was too shy for just singing, so we started to walk through the therapy room, I started to make sounds with my voice in our walking tempo, and the patients was able to join in. You see, how she moves and even starts to dance.

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FIGURE 13.

Episode “playing and singing”

Bodily experience in active music therapy is also connected with the „musical roles“ and „initiatives for changes“ as you saw it in the first episode.

I´ll play it again now. Please notice the sequence after we change our mode from playing simulatenously to an alternating, dialogic one, the patient involves his body more into his playing.

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Results

FIGURE 14.

Episode “becoming playful”

The last episode is from the same patient; it´s out of his 10th session and shows, how he transfers his experiences from singing to his playing on a marimbaphone.

His attitude and his idea about playing an instrument changed completely. He communicates with body movements and with an initiative and dynamic playing.

He titled this improvisation: „Swing in my brain“.

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FIGURE 15.

Episode “Swing in my brain”

Summary To summarize, I would like to quote from the music therapy interviews, what the patients said about their music therapy experience.

Nine out of ten participants described that it was very important for them to become personally active.

All ten participants reported an immediate improvement in their well-being during the sessions. For eight of them this state continued till the next day and was confirmed by partners or colleagues.

Seven participants described an enhanced perception of themselves with an increasing self-confidence over the course of the therapy. They were increasingly able to let themselves be surprised by their music and by their own previously undiscovered skills.

Music and music therapy are experienced as „something moving“ that reduces negative thoughts about the disease and offers a means of expression for feelings of security, freedom and pleasure.

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References

References Alcock, G., Chambers, B., Christopheson, J., Heiser, D. und Groetzinger, D. (2001). Complementary and alternative therapies for Multiple Sclerosis. In J. Halper (Hrsg.), Advanced concepts in multiple sclerosis nursing care (S. 239-266).

New York: Demos Medical Publishing.

Aldridge, D. und Aldridge, G. (2002). Therapeutic narrative analysis: A methodological proposal for the interpretation of music therapy traces. http://www.musictherapyworld.de/modules/mmmagazin, Ausgabe 12/2002.

Kelly, G. A. (1955). The psychology of Personal Constructs I & II. New York: W.W. Norton & Company.

Magee, W.L. (2002). Identity in clinical music therapy: Shifting self-constructs through the therapeutic process. In R. MacDonald, D.J. Hargreaves u. D. Miell (Hrsg.), Musical Identities (S. 179-197). Oxford: Oxford University Press.

Rothwell P.M., Dowell, Mc Z., Wong, C.K. und Dorman P.J. (1997). Doctors and patients don´t agree: Cross sectional study of patients’ and doctors’ perceptions and assessments of disability in Multiple Sclerosis. British Medical Journal 314, S. 1580-1583.

Schmidt, H.U. und Hennings, U. (1998). Gruppenmusiktherapie bei Patienten mit MS. Dokumentation des 10. Ulmer Workshops 1998. S. 70-81.

Springer, A., Clark, S., Price, E. und Weldon, P. (2001). Psychosocial implications of Multiple Sclerosis. In J. Halper (Hrsg.), Advanced concepts in Mulitple Sclerosis nursing care (S. 213-237). New York: Demos Medical Publishing.

Wiens, M.E., Reimer, M.A. und Guyn, H.L. (1999). Music therapy as a treatment method for improving respiratory muscle strenght in patients with advanced Multiple Sclerosis: A pilot study. Rehabilitation Nursing 24, 2, S. 74-80.

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Music Therapy Today, Vol. VI, Issue 4, (November 2005) a publication from MusicTherapyWorld.net

CHAPTER 50

Change - Illustrated by a case in active music therapy as personal growth

Schou, Karin schou@musikterapi.org

Summary The basis of this thesis is a qualitative retrospective case study in active music therapy as personal growth which is chosen as an illustration of change. The author is both the music therapist and the researcher of the study.

The object is to make research into what change as a phenomenon can be in the specific case, and what the function of the music is in the process of change.

The client is a self referred woman who wants to work with a particular communication problem. The intensity of the music therapy and the unfolding of the change process filled me with awe and made me curious to examine the complexity of this process.

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Change - Illustrated by a case in active music therapy as personal growth

In the first chapter of the thesis central concepts are explained as well as the author’s previous knowledge in relation to the object of this research. The basis of the therapeutic approach is Analytical Music Therapy.

The main emphasis is laid on the case, which is introduced and described in chapter two.

The client “Anna” is a normal, intelligent woman in her early thirties who finds herself inhibited in her communication due to her polarized self image, which she wants to change during the music therapy of eight sessions.

During the music therapy the polarization and its components become clear. The theme of control and letting go is expressed in the metaphors the ‘judging head’ and the ‘playful heart’. By allowing herself to become present in the here-and-now, Annas contact with herself is established. This process of change allows Anna to experience feelings that were previously judged by her head as ‘wrong’. In free tonal improvisation Anna explores these feelings and the relation between her head and her heart. At the end of the music therapy she has obtained an ability to distinguish what is in her heart and in her head, and she is able to decide which relation between control and letting go is right for her for the time being.

In chapter three the author’s therapeutic practice is reflected theoretically. The theories included are selected in accordance with her view on human nature and her therapeutic approach.

The perspectives on change as a phenomenon are reviewed in the theory of analytical psychology and in an existential theory, and specific concepts are explained.

The transformation principle is the basis of change, and self-realization is seen as a basic human need, which is closely related to creativity and the ability to play. A theory on play and reality is included to contribute to the reflection on play as a parallel to free tonal improvisation as it is employed in active music therapy.

The object of therapy in relation to change is illustrated. How a change process is initiated and which roles responsibility and will play in this is explained. In ending this chapter the contribution of the selected theories as to their reflection of the therapeutic practice are explained.

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Summary

In chapter four the phenomenological / hermeneutic analysis elaborates on the questions what change can be, and go into details of change in the process, in the relation and in the function of the music. Five improvisations (music examples) are selected and illustrated visually in graphic notations. Two client reports are obtained in the forms of a questionnaire and a semi structured interview. In validating and contributing nuances to the analysis, a phenomenologically inspired research is carried out in structured listener interviews.

Each music example is vertically analysed and the chapter concludes by the horizontal analysis of change in the process in its entirety, and change is explained in the theoretical frame of understanding.

The analyses show how Anna by expressing her sense of powerlessness in music allows for its opposite, omnipotence, to be expressed. In surprising Anna this music awakens her creativity and her ability to play. The music clarifies Annaâ&#x20AC;&#x2122;s polarized self image in a way that connects her with the underlying frustration.

By way of projective identification the function of control is played out by the therapist making room for Anna to let go in the music and to explore what relation between her head and heart are appropriate for her for now.

A progression in the process proves particularly clear in the first three music examples.

The analyses also show changes in the relation during the music therapy as different levels of interacting in the potential space between therapist and client are developed.

In chapter five the findings are discussed in relation to the research questions asked.

The discussion therefore falls into two parts: one relating to the object of this thesis and the other relating to the research method.

In selecting the music examples an interim definition of change is hermeneutically transformed into a list of nine criteria that describe a phenomenon, which may be called change. All criteria are met in the change process as a whole in this case.

Each change phenomenon can meet some of the criteria.

Triangulation of sources has contributed to the validation of this study. A possible simplification of the procedure of the listener interviews is discussed.

In conclusion, change as a phenomenon in this case shows to be as follows:

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Change - Illustrated by a case in active music therapy as personal growth

• The need for self realization is carried out in the client’s need to change her self image

• Creativity awakens as the client surprises her self and is engaged in the hereand-now

• The client sees possibilities in stead of inhibition which exemplifies a creative approach to life

• The relation develops through four levels and the role of the therapist changes as the potential space is established, used and expanded

• Existentially the client finds her personal way of dealing with the challenges of life by deciding which relation between control and letting go is right for her

• In an analytical psychological perspective the psychic structure of the client becomes more flexible

• The process in parts and as a whole consist of four levels of relating to the process

• Change is realized in four existential dimensions • Responsibility and will show in the client’s ability and will to be present in the here-and-now at times of emotional challenge

The music has the following functions in the change process:

• Music as a field of play allows the client to explore former unconscious feelings and support her being present in the process here-and-now

• Music helps the client to let go • Music allows for the client’s exploration of her omnipotence • Music reflects the polarized self image of the client and connects her to its frustration

• Music creates the potential for a dialogue between opposite poles • Music makes room for the client to express and embody a new psychic structure • Music reflects the relation and its levels of interaction throughout the change process

The theory of gestalt therapy and levels of contact could contribute with different perspectives on change processes, as could Stern with his minute research into the interactions of infants and their primary care taker.

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Summary

This case is one illustration of change processes, which cannot be generalized. May others be inspired to further elaboration into this basic condition of life.

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Music Therapy Today, Vol. VI, Issue 4, (November 2005) a publication from MusicTherapyWorld.net

CHAPTER 51

Music therapy in psycho-oncology â&#x20AC;&#x201C; A gender comparison

A research project of the Master´s Degree programme in Music Therapy, University of Applied Sciences Frankfurt/Main, Germany

Seidel, Almut

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Music therapy in psycho-oncology – A gender comparison

Abstract This article documents a music-therapy research project in the psycho-oncological care of both, male and female cancer patients at the transition point between curative and palliative care in their illness. This article discusses the far-reaching implications at the institutional, conceptual, methodological and personal levels. In addition to the detailed description of this field of work, there is a focus on two particular aspects of the research results: first, gender-specific reception to the opportunity of having music-therapy and second, the relationship between the spoken word and making music in the therapy sessions, with the potential of each as an integrating or polarising healing factor.

Introduction The gender study that I will report in this talk is based on the following data:

• • • • •

work with cancer patients

• • • • •

exactly the same numbers of male and female patients

with different types of cancer in 3 hospitals patients of all ages, with a concentration between 21 – 68 years stadium of the illness is the transition point from curative to palliative treatment * working with male and female therapists emphasis on individual active music therapy with exclusion of vocal work research attention paid to the musical as well as verbal interaction combination of qualitative and quantitative research approaches

*In fact, we now know that six months after completion of the data collection phase of the project more than 50% of the patients had died.

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Aims

Aims The intention of the study is to find out what music, working with music and the therapeutic setting means in working with cancer patients and how patients of both sexes receive it. Our initial hypothesis was: We suspect that there must be differences in the way that cancer patients make use of the possibility of music therapy due to the following factors:

• the seriousness and finality of a diagnosis with cancer on the one hand, • and, on the other, the nature of music and music therapy: that is, that music as a therapeutic agent appeals to the emotionality, expressiveness and ability of the patient to be in dialogue, and that music therapy encourages active and creative coping strategies.

The degree to which this response is gender specific, or the degree to which there is a gender-specific approach to coping with the illness seems to be an important question (Brähler & Felder 1999; Meadows 2002).

We began work on this project in the spring of 2002 and will complete it by publishing our results in book form (Seidel 2005).

I will now like to describe our research design which is shown in the following table.

TABLE 1.

Research design Local Practitioners

External Describ

• Hospital 1

• • • • •

Music therapist 1 f-> 6 Patients f -> 6 Patients m

• Hospital 2 Music therapist 2 f -> 6 Patients f -> 6 Patients m

Describer 1 Describer 2 Describer 3 Describer 4 Coordinator

• Hospital 3 Personal level

Music therapist 3 m-> 6 Patients f -> 6 Patients m

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TABLE 1.

Research design

• Patient statistics (230 Patients) • Patient data (36 Patients) • Short description of the course of therapy (36 Patients)

• Audio recording of one selected session per

• Music descrip-

tions from 18 selected patients using morpholog ical method

patient

Data / Material Level

• Music descriptions by patient and therapist of improvisation from selected session

• Quantitative Pre- and Post-Test • External situation:

• Setting variables and conditions

• emotional coping • Internal situation:

• Relationship between verbal and musical interaction

Evalu-ation / Interpretatio n Level

• Pre- and Post-Test • Gender comparison

Methods SUBJECTS AND INTERVENTION

We have three groups of persons who have taken part in the project: 1.

2.

3.

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strategies, assumed effect

Methods

You will see that we have attempted to have balanced representation of men and women in each group (Behnke & Meuser 1999; Strauss 1991).

The local practitioners were charged with giving us a bundle of material; you can see this in Table 1 on page 1460 on level 2, the data and materials level. We received statistics, that is, an overview of patients treated, from a year’s work from each therapist. This included data concerning sex, age of the patients, and the number and length of sessions as well as the method of work in the sessions. At this level we divided the methods used into three general categories:

• active music therapy • receptive music therapy • talking without music DATA COLLECTION

Then a selection of 12 patients per therapist, 6 male and 6 female, was made based on the work of the practitioners from approximately the previous 18 months. The selection of patients was made by the therapists themselves after we had determined the total number of patients we wished to have. We received personal data for each patient including a short medical history and a summary of the treatment given in hospital. Therapists documented the course of the therapy by making notes after each session. Here we asked for detailed information about the methodological approach including making music, listening to music, playing for the patient, body work, etc.

Out of the total course of therapy with each patient, the practitioner selected one session that he or she subjectively felt was significant in illustrating the therapy process or the situation of the patient. We received an audio recording of this session. One of the music improvisations in the session was described by the patient – as much as was possible for him or her. This was important for the research design and so the therapists gave the patients enough time and space to describe their experiences of making music. Afterwards the therapists also wrote a description of the music from their perspective.

QUESTIONNAIRES

In addition, patients were asked to fill out a questionnaire before and after each session documenting the way they felt. The instrument used was the “Basler Befindlichkeitsskala” (BBS). The questionnaire (Hobi 1985) comprises 16 items such as

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• calm and nervous • withdrawn and open • attentive and distracted that are grouped into 4 main categories (see Basler Scale: four sub-groups ). The sum of the values for all four give an overall value for the condition of the person.

FIGURE 1.

• • • •

Basler Scale: four sub-groups

intra-emotional state of balance vitality alertness social extroversion

BLINDFOLD MORPHOLOGICAL DESCRIPTION

For the evaluation of the improvised music we chose the Salber’s method of morphological description through which one can describe the experience of emotional or psychological events (Salber 1980). Only the unbiased emotional response of the listener to the emotional state being expressed by the other person gives access to the fundamental inner state of the other. On a comparable level, the expert’s listening to the improvised music is the morphological descriptive work. Without any further information about the case, the expert listens to the music and then writes down impressions, images, associations, stories, memories and reactions elicited by the music heard.

We modified the morphological approach in the following ways in order to achieve our goals: we asked 4 music therapists to undertake this descriptive work independent of each other and without any knowledge of the source of the music they were hearing, in a blindfold experiment. This means that they received no information about where session had taken place, nor the identities of therapist and patient, about the illness and the clinical background nor the question our research was attempting to answer. In this context, you can see why we excluded vocal elements (Tischer 1993) in the sessions selected for analysis.

The describers were asked to listen to and describe the music on 5 consecutive days. We wanted to see if the experience of the music changed or solidified when listened to in such an intensive way. Of course, we also wanted to make use of 4

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Methods

different ways of hearing and experiencing the music. And so, we speak of an internal and external comparison.

The selection of patients whose music was sent to the describers was made from those for whom a full set of data was available; the selected improvisations also typified the responses of patients and therapists in the music therapy session – these characteristics had become increasingly clear through our memos.

TRIANGULATION

All methodological steps were decided in the core team in which three subjective perceptions confronted each other (Hurrelmann & Laaser 1998; Soeffner 1979).

So, in the total evaluation of the data, we are dealing with three viewpoints, that of the local practitioner, the external describer and the core team: we hope that this approach assures controlled subjectivity.

FIGURE 2.

Triangular dynamic

• music therapists as local practitioners • external describers in blindfold experiment • core team of experts In order to explore the connection between the verbal and musical interaction of a session, we transcribed 13 of the 18 sessions that we had as audio recordings. The selection was made in order to have a balance of male and female patients as well as to cover the work of all the therapists in local practice. We decided not to transcribe all 18 sessions because at a certain point the research material was saturated.

Inclusion of this material was not planned from the beginning; we made this decision in response to the tension which became apparent between the external describers’ perception of the music and the rest of the data on hand.

The purpose of this comprehensive and carefully documented collection of data can be seen in table 1 on the 3rd level – the evaluation and interpretation level. We considered the so-called external circumstances – the questions of time and place, the instruments selected, the presence of other people and so on – in order to deduct a pattern under which the therapy was conducted. We wanted to discover this pattern in order to make a contribution to the discussion on concepts of music-therapy in

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the clinical context. Results can be found in the book published in 2005 (Seidel 2005) Then the question arose of how patients deal with the music therapy through their experience and behavior, and how to assess the effect of music therapy work. It was necessary at this point to reduce the data and focus it in order to elicit themes from it. We used two theoretical models as screens through which to look at all the data we had on each patient with specific attention to themes which were significant with regard to coping with the disease.

1.) FIVE LEVELS OF AWARENESS

The first model emerged from the data itself: we identified 5 levels of awareness that are particularly important for patients with cancer. These core categories are:

• • • • •

physical or body awareness emotions imagination ideas or thoughts/understanding interaction with others

Table 2 shows the evaluation sheet we developed and used to work with the data we had.

TABLE 2.

Evaluation sheet

Client:

Session:

Instrument client:

Awareness level

physical

emotional

before the session until music production begins

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Instrume

imagination

understa

Methods

TABLE 2.

Evaluation sheet

External describer’s experience of the music Music therapist’s experience of the music Patient’s experience of the music after the music production phase

You can see in table 2 that we divided the information into an objective section based on the notes of the session, and a subjective one based on the descriptive level. Both levels were then compared and an interpretation was derived.

The process of working with this comprehensive amount of data was as follows: each of the three experts on the research team reviewed the data independently and began to reduce it to a more compressed form. Then working together, all emphases that were commonly agreed upon were entered into the tables and used for interpretation.

2.) MULTI COMPONENT MODEL OF EMOTION

Now to the second model: In order to make a gender comparison and to make the qualitative data quantifiable (Behnke & Meuser 1999), as well as to generate a theoretical model, we used a model which stems from the psychology of emotions. This multi-component model includes: FIGURE 3.

Emotion model (Bernd Tischer 1993) version I

• subjective experience (emotion)

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• • • •

cognitive (and imaginative) experience physiological process (body experience) interaction behaviour situational aspects

The model emphasizes the process character of emotionality and examines the function of emotional development in interaction; these are put into a valencing scheme and allow a method of measurement that results in identifying so-called emotion types. In this way a quantifiable instrument is introduced that allows us to develop our results within a broader theoretical model and thereby in an established theory, thus making a bridge to the scientific community. The inter-connection between our data categories and the emotion concept are shown in the next table 3.

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Methods

TABLE 3.

Quadrantenmodell

1

2

Away from oneself - Patient controls the surroundings

Toward oneself â&#x20AC;&#x201C; Patient controls th

Physical level: Patient is very tense

Physical level: Patient is energized

Emotional level: Pt. is angry, rejecting, under pressure

Emotional level: Patient is able to fe

Imagination: Images of (struggle for) survival

Imagination: rich imaginative abilit

Understanding: Patient feels autonomous

Understanding: Pt. actively seeks w

Interaction level: Patient controls every contact

Interaction level: Patient is in dialog

Tendency to act:

Tendency to act:

Patient feels under attack and resists with intensity

Patient signals what he/she wants an

3

4

Away from other(s) â&#x20AC;&#x201C; Surroundings control the patient

Toward other(s) â&#x20AC;&#x201C; Surroundings con

Physical level: Patient is in pain, strength for living is waning

Physical level: Patient is cut off from

Emotional level: Patient feels afraid, sad, depressive

Imaginations: Images of dissolution

Imagination: Images of helplessness

Understanding: Patient lets everyth

Understanding: Patient feels dependent on others, not in control

Interaction level: Patient desires fee

Interaction level: Patient is withdrawn, not in contact Tendency to act:

Emotion: Patient longs for deliveran

Tendency to act: Patient gives in and gives up

Patient closes down and retreats from living

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SEQUENTIAL TEXT ANALYSIS

In order to explore the relationship between the verbal and musical interaction, we used the method of sequential text analysis of the transcriptions of the audio recordings. This method involves four steps (see Oevermann 1979): 1.

2.

3.

4.

Transcription of the verbal material in the session with medium exactness Documentation of the obvious structure of the text by sequential paraphrasing of the sections of the transcript Extensive interpretation of the latent meaning structure using Oevermann’s objective hermeneutic method Comparison of the descriptions of the verbal text and the descriptions of the music

The last step in the analysis of the material was the statistical analysis of the preand post-test. I will talk about some of the results later.

GENDER COMPARISON

Finally, the gender comparison was an aspect of the concluding assessment and interpretation of the research results.

Interpretation and critical appraisal of the research results In our analysis we dealt with three issues: 1.

2.

3.

The question of method: active and/or receptive music therapy, talking The institutional dilemma: resistance / music therapy as intermediate space Gender main streaming – also in music therapy?

1. THE QUESTION OF METHOD: ACTIVE AND/OR RECEPTIVE MUSIC THERAPY, TALKING

We have overwhelming evidence in our research that music therapy in oncology is in most cases receptive, that is sound meditation on the monochord within a guided relaxation in which music takes over a background function (Verres & Rittner

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Interpretation and critical appraisal of the research results

1997). This form of music production is not musically or therapeutically very demanding and can easily distort the image of music therapy as a profession.

Rarely, there is also a special form of receptive music therapy which is called “FürSpielen” in Germany, which means that the therapist plays simple instrumental music for the patient.

The therapists gave us the following reasons for this: The patients are physically too weak. They are completely exhausted, their pain is overwhelming and they are challenged enough in other areas. Usually they are not able to walk or must stay in bed to receive infusions. These are plausible reasons, which cannot be dismissed.

Consequently our research design proved to be misconceived since active music therapy appeared as an artefact. A certain pressure existed to acquire the patients for the research. In order to fulfill the research design, the therapists made an effort to change their strategy and to do more active music therapy – whether at the bedside, in the patient’s room or in the music therapy room.

Then came the first insights: it does work to do active music therapy! It brings results, perhaps even more than receptive music therapy. What is this “more”?

Receptive music therapy fits in with the courses of medical treatment: a specific therapy is administered (medication, radiation, operation) and then one waits for the effect. Apart from bearing and suffering through all the side-effects, this waiting is the only active step in the healing cycle (Verres & Klusmann 1997; Gruhlke, Bailer & Kächele1999; Kappauf & Gallmeier 1995).

Receptive music therapy is the same procedure: in this case a sound induction is „administered“ and one hopes for the relaxation and wellness effect. When this offer is matched with a significant amount of suggestion with regard to the positive effect of the treatment, a degree of autosuggestion cannot be excluded. This carries on through the post-test. It is simply assumed that the expected positive effect has been achieved, or is confirmed by the largely positive comments of the patients, to the degree that they express themselves at all.

Active music therapy, on the other hand, is a challenge to patients to give up this stance of being a receiver and to take the instrument of healing literally into their own hands. In that the patients take the initiative they can overcome some of the regressive tendencies that the illness brings with it. This encourages them to produce their autosuggestion in another direction, namely “I can still do it, that has nothing to do with my illness and the physical and emotional restrictions, that is a

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field with no land mines, that is harmless.” They experience music making as a small step in the direction of reclaiming their autonomy which they have largely relinquished in hospital; they can “forget” themselves a little – that is, they can forget the “sick” self for a time (Weber 1999).

It becomes clear to the patient, either explicitly or implicitly, that music therapy can achieve something that lies between, between relaxation and self-healing (DeckerVoigt & Escher 1994). Actively produced music can make tensions audible and ideally can regulate tension. It can make audible what patient is not able to express in words: his restlessness and inner conflict, his anger, resignation, physical and emotional numbness and feeling forlorn (Aldridge1999). The patient can also feel his deep desire to full life strength and his passionate yes to living even if this is an illusionary dream and a sad longing for unattainable harmony. Active music therapy is appropriate for persons who are not able to speak about their condition but are willing to listen attentively to their own being. This is, however, far removed from relaxing, distraction and relief or from simple “balsam” for the soul, as one patient said (Verres & Klusmann 1997).

2. THE INSTITUTIONAL DILEMMA: RESISTANCE/ MUSIC THERAPY AS AN INTERMEDIATE SPACE

We asked ourselves what makes it so difficult to do active music therapy? Why hasn’t active music therapy become the method of choice, why is it, in fact, occasionally avoided?

We became aware of another contradiction: In the analysis of the verbal interaction we realised that therapists take pains to describe what the positive effects of music therapy can be; this often takes the form of extensive instructions. It also became clear that patients speak very little about their emotional experience after they have made music. Often, if they talk at all, they focus on external aspects such as how to handle the instrument or how it was constructed or they talk about their previous experiences with music. If there is talk about the music just produced, therapists tend to make positive value judgements and toward euphemisms. It seems that something is contained in the music which is excluded from conscious examination.

On the whole the patients experience the contact as positive and they are interested in this form of therapy. This is shown in the few statistically significant results of the pre- and post-tests: the analysis showed that there was a significant increase in

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Interpretation and critical appraisal of the research results

figures for all four factors as well as for the sum of the four, clearly documenting that patients experienced positive benefits from music therapy.

A different picture is revealed in the description of the music:

• There is no real understanding of the suffering of the patient, neither by the patient nor the therapist.

• Other feelings appear, such as feeling forlorn, loneliness, not being noticed, losing oneself or falling apart. Feeling of numbness and being at the mercy of external influences.

• In being with someone, which is so much desired, something always drifts apart and destroys the hint of commonality.

• The loneliness cannot be abolished.

• There seems to be a compulsion to believe that all will be well, that all is possible and convincing. However: true conviction is missing.

• Not-understanding actually cloaks rejection.

• The patient has to go through “hell” alone (the certainty of disease, the suffering, death); one can accompany the patient, but can offer him or her no real help.

These findings are confirmed and quantified through the typology of the emotions model; the type of patient that can most often be identified with equal representation of men and women is Type 3. I will show you this segment of the quadrant model (Table 3 on page 1468) again.

FIGURE 4.

Type 3

Away from other(s) – Surroundings control the patient

• • • • •

Physical level: Patient is in pain, strength for living is waning Emotional level: Patient feels afraid, sad, depressive Imagination: Images of helplessness Understanding: Patient feels dependent on others, not in control Interaction level: Patient is withdrawn, not in contact

Tendency to act: Patient closes down and retreats from living

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There seems to be method in the contradiction in the findings. One could describe it as repression of the oppressive reality and as resistance.

How can this be explained?

The music therapy work in our research project dealt with 6 conflict fields that produce the reaction of resistance.

1.

2.

3.

4.

5.

6.

general image of music in our society hospital’s instructions on purpose of music therapy music therapist’s professional understanding research design – focus on active music therapy resistance of the patient tension between curative and palliative care

First of all, there is the general image of music that prevails in our society. Music seems to be something very nice and always makes you feel good. Music relaxes and regulates feelings; music lifts our spirits and makes us happy. And if it doesn’t do that, we turn it off – literally, also in the sense of not dealing with it.

Secondly, the hospital expressly instructs the music therapist to make a contribution to securing the compliance of the patient. The patient is to feel as well as possible under the circumstances.

Thirdly, there is the professional understanding of music therapy, which means using music and the music therapy setting to cope with the illness. Ideally, this means depiction of the conflict and resolution. In this regard, there are principally no limitations to using all methods that are recognized as music therapy. But it is also clear that music therapists have a very sophisticated understanding of the effect of music. And therefore, they cannot exclude the possibility that music will produce other responses than calmness, relaxation, and relief.

Fourthly, the research design called for the investigation of active music therapy. However, it was soon apparent that this was and is not the rule in practice of music therapy in psycho-oncology.

Fifthly, we are dealing with the resistance of the patient which we could describe as protective resistance. This is understandable in the light of the desolate physical condition of the patients and in the light of the demands that the other treatments make on them. Furthermore, active production of music provides a wealth of new

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Interpretation and critical appraisal of the research results

and unusual experiences so that the patient undoubtedly experiences it as quite demanding.

And finally, the sixth conflict field is the tension between curative and palliative care. As long as medical treatment is based on the hope that life can be prolonged for the patient, the music therapist must fit in so that he or she does not undermine these efforts. And therapists certainly do not want to lose their jobs. So their orientation remains diffuse and becomes an individual problem to solve. It would be much easier to conceive of and carry out music therapy as pure palliation.

Thus, music therapy is pulled in many directions.

But something does take place in the course of active music therapy, possibly in receptive music therapy as well – that is documented by the external expert’s assessment. This can, perhaps, be explained as follows: Hospitalization means that, although all are fully aware of the potentially lethal outcome of the illness, everything possible is being done to save life (LeShan 1999).

This is the ethical principle, and so hope must be the dominant attitude (Aldridge 1999). This is the internal stance of the medical staff, otherwise a professional identity would be unimaginable.

This principle can be maintained everywhere else – but not in music. Since music affects the unconscious of an individual, the patient cannot control the elements that begin to surface. What is working in the unconscious of the patient finds an outlet.

In this context, Winnicott’s model of „intermediate space“ was helpful for us. It serves as a bridge between inner and outer realities. The inner realm is the individual and her experiences. The outer realm is the surrounding reality, in this case, the illness, treatment objectives and methods.

The music generated by patient and therapist functions as intermediate space as

• the inner reality does not remain hidden but is brought into the open • what is brought into the open does not need to be put into words, in that it has already found a form of expression

• having expressed the inner reality, it is „enough,“that is, the „thing“ has been

given a name – the monster of death, illness, destruction, hopelessness has been given a face, or a sound.

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Therefore, music therapy should be understood as

• the space into which this experience from the borderlands can flow without having to be put into words or grasped mentally.

• a place where these truths can exist and must not be banned as they are in the clinical and private daily reality.

• an opportunity for that which is incomprehensible, nonetheless, to be grasped

emotionally. The music shows that although the patient is not yet able to understand the illness, the threat and the knowledge of his own fleeting life, the music produced shows that the spirit of the person has already apprehended this reality.

3. GENDER MAIN STREAMING – IS IT RELEVANT FOR MUSIC THERAPY?

In our research a common observation was confirmed: As long as there is no conceptional obligation, thereby no institutional monitoring, men are excluded from psycho-oncological music therapy.

• N=148 Patients in 3 clinics • Women 104 = 72% • Men 42 = 28% If they end up in music therapy, either through their own initiative or by chance, through something like gender-focused research (Brähler & Felder 1999; Behnke & Meuser 1999), then they are more likely to experience receptive music therapy if there is music at all (Krantz 1999).

TABLE 4.

Women Men

Methods used Active MT

Receptive MT

Talking

26%

50%

24%

19%

33%

48%

This confirms a common cliché – that men enjoy being waited on by women, they take what supposedly belongs to them without making any efforts of their own,

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References

they avoid emotional conflict (Brandes 1992; Hollstein 1999). But they remain alone in their suffering (Neumann & Süfke 2004). A two-class society is created. „There is no gender-neutral reality”, is one of the basic tenets of the gender-mainstreaming movement (Kolip 2000; Meadows 2002). The assumption is that all societal enterprises, also music therapy, wherever they are found, should take into account the life situation and interests of both men and women from the beginning and throughout the further development of the initiative. The goal is the equality of both sexes.

At no time or place anywhere in the world has there been any indication that men have a less intensive, less motivated, less elementary or emotional approach to music (Sieg 1995). Men may demonstrate a different affinity for music than women, or may conceptualize it differently, but they need music just as urgently as a life-giving, and life-preserving element in their lives as women (Krantz 1999).

That is even more true in such extreme situations as life-threatening illness (Aldridge 1999; Renz 2000).

We did not document any differences in behaviour, in approach to music therapy, or in results of the therapy between the 18 male patients and the 18 female patients in the study. This applies to all parameters that we studied – from the choice of music instrument and its use, to the transition from talking to making music and viceversa and to the statistics of the pre- and posttest.

We have attempted to show that the clinical reality – when not influenced – makes differences and that the practice of music therapy is far removed from the ideas of gender-mainstreaming. Carrying these ideas into the professional field of music therapy and in the training programmes was and is one of the intentions of this study. In our eyes, psycho-oncological music therapy is a particularly vivid and impressive example of the quality of perception and feeling, the ability to listen to the interior realities and to put them into external expression as a way of coping with illness and life that men as well as women need (Maschewsky-Schneider 1997). Men need it no less, no less naturally, or unquestionably than women. In my eyes, professional quality and responsibility begins at this point.

References Aldridge, D. (1999) Musiktherapie in der Medizin. Forschungsstrategien und praktische Erfahrungen. Bern: Huber

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Behnke, C.; Meuser, M (1999) Geschlechterforschung und qualitative Methoden.

Opladen: Leske und Budrich Bilek, A (1999) Musik bei Krebs? Gedanken zu psychoonkologischen Modellen.

Musiktherapeutische Umschau 20, 4, 325-341.

Brandes, H. (1992): Ein schwacher Mann kriegt keine Frau. Therapeutische Männergruppen und Psychologie des Mannes. Münster: Votum Brähler & Felder (Hg) (1999) Weiblichkeit, Männlichkeit und Gesundheit. Opladen Decker-Voigt, H.H.; Escher, J. (1994) Neue Klänge in der Medizin. Musiktherapie in der Inneren Medizin. Düsseldorf: Trialog Gruhlke, N.; Bailer, H. & Kächele, H. (1999) Krankheitsbewältigung bei Krebsein kurzer Überblick. Musiktherapeutische Umschau 20, 4, 342-349.

Hobi, V. (1985) Basler Befindlichkeits-Skala. Weinheim Hurrelmann & Laaser (Hg) (1998) Handbuch Gesundheitswissenschaften. Weinheim Hollstein, W. (1999) Männerdämmerung – Von Tätern, Opfern, Schurken und Helden. Göttingen: Vandenhoeck Kappauf, H.; Gallmeier, W.M. (1995) Nach der Diagnose Krebs - Leben ist eine Alternative. Freiburg: Herder Kolip, P. (2000) Weiblichkeit ist keine Krankheit. Weinheim Krantz, B. (1999) Geschlechtsspezifische Aspekte in der Musiktherapie.

In: Beiträge zur Musiktherapie. Berlin: Eigenverlag Deutsche Gesellschaft für Musiktherapie (DGMT) LeShan, L. (1999) Psychotherapie gegen den Krebs. Stuttgart: Klett-Cotta Maschewsky-Schneider, U.(1997) Frauen sind anders krank. Weinheim Meadows, A. (2002): Gender Implications in Therapists’ Constructs of Their Clients. Nordic Journal of Music Therapy Vol 11, Issue 2

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References

Neumann, W.; Süfke, B.(2004): Den Mann zur Sprache bringen. Psychotherapie mit Männern. Tübingen: DGVT - Verlag Oevermann, U. et al (1979) Die Methodologie einer "objektiven Hermeneutik" und ihre allgemeine forschungslogische Bedeutung in den Sozialwissenschaften, in: Soeffner, H.G. (Hrsg.) Interpretative Verfahren in den Sozial- und Textwissenschaften. Stuttgart Renz, M (2000) Zeugnisse Sterbender: Todesnähe als Wandlung und letzte Reifung.

Paderborn: Jungfermann Salber, W. (1980) Konstruktion psychologischer Behandlung. Bonn Seidel, A. (2005) Verschmerzen. Musiktherapie mit krebserkrankten Männern und Frauen im Spannungsfeld von kurativer und palliativer Behandlung. Wiesbaden Sieg, A. (1995) Eine Männergruppe in der Musiktherapie. Musiktherapeutische Umschau 16, 1, 43-53.

Soeffner, H.G. (Hrsg.) Interpretative Verfahren in den Sozial- und Textwissenschaften. Stuttgart, 1979 Strauss, A.L (1991) Grundlagen Qualitativer Sozialforschung. München Verres, R.; Klusmann, D. (1997) Strahlentherapie im Erleben der Patienten. Stuttgart: Hüthig Medizin Tischer, B. (1993) Die vokale Kommunikation von Gefühlen. Weinheim Verres, R. / Rittner, S. (1997) Musiktherapie und High-Tech-Medizin: ein Widerspruch? - Entwicklung eines musiktherapeutischen Konzeptes. In: Verres/Klusmann, Strahlentherapie im Erleben der Patienten. Stuttgart: Hüthig Medizin Weber, S. (1999): Vergessen wo ich bin... Musiktherapie mit Krebspatienten während der Chemotherapie. In: Kraus W, Die Heilkraft der Musik, 186-193. München: Beck

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Author Information l

Almut Seidel, Prof. Dr., school music teacher, musicologist, roman language, education science, psychology, sociology. Master of Education (Diploma); Talks, lectures, publications and research on children, addiction, elderly. Since 1971 at University of Applied Science Frankfurt, since 1988 head of master studies in music therapy; active in several professional organisations for music therapy.

This article can be cited as: Seidel, A. (2005) Music Therapy in Psycho-oncology – A Gender Comparison. Music Therapy Today (online) Vol. VI, Issue 1 (February), p. 60-85. Available at http:// musictherapyworld.net

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Music Therapy Today, Vol. VI, Issue 4, (November 2005) a publication from MusicTherapyWorld.net

CHAPTER 52

Phenomena of health and pathology in music therapy

Sekeles, Chava (OTR; RMTI.) Israel

Abstract In the following presentation, I will describe and analyze specific recurrent phenomena that emerge during the process of music therapy and represent or symbolize real-life issues. These include phenomena of health as well as of pathology, which enable us to diagnose and make therapeutic considerations. From positive musical aggression, constructive ventilation and lamentation to the phenomenon of repetitive monotonic drumming (devoid of changes in rhythm and dynamics) characteristic of cases involving pathological mourning; difficulties in beginning instrumental playing, typical in cases of expressive aphasia; musical components of passive-aggressiveness; musical expression of defense mechanisms; musical components of compulsive-obsessive behavior; cutting the end of sentences in songs, typical of certain psychiatric disorders; splitting and more. The presentation will combine theory and practice, followed by recorded and video-filmed examples.

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Introduction We accept the musical expression in music therapy as meaningful, even when it sounds very simple, or “not musical”, or primitive. The artistic meaning is not the issue but rather the psychic content that emerges in between and behind the lines.

This content might use music as a symbol, representation, direct expression of emotion, etc. Most often, the patient expresses a feeling in his/her musical action long before he/she is able to do it verbally and typically without being aware of the expressive content. In active music therapy, in which improvisation is one of the main techniques and approaches, the musical chains act as free associations in verbal analytical therapy. Most of the activity begins at the subconscious level, but gradually this process might help patients become better connected with their authentic experiences. In free association, key words can facilitate understanding of inner content. So do key musical events, motives or repetitive elements in clinical improvisation. Indeed, a music therapist must listen carefully to the double meaning of the patient’s musical manifestation and analyze the pure musical content as well as the extra-musical analogies.

A. Splitting Danny1 was eight years old when he was first referred to music therapy. Born after a full-term pregnancy, at the age of few months he began to show signs of uncontrolled rage and temper-tantrum. His parents, both in medical professions, firmly rejected intervention and tended to blame the nursery system. As a result, the child was moved from one nursery school to another, unable to develop any ongoing bonds. In elementary school, he failed to cope with academic requirements and social demands: his aggressiveness endangered children and staff, he regularly threw stones and other objects at people, stabbed peers with knives stolen from the kitchen, could not concentrate on his studies, and despite his normal intelligence and learning abilities, at the age of eight he still could not read, write or calculate.

Danny was soon named The Devil by his class mates, and found himself socially isolated. Subsequently, his parents were compelled by school authorities to search out the psychiatric intervention, and Danny was diagnosed as suffering from an Organically–based Developmental Disorder. During four months of psychiatric

1. All names are fictitious in order to keep the professional ethics.

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A. Splitting

treatment, Danny did not cooperate and the psychiatrist recommended music therapy, stating the following reasons: the child has natural tendencies toward music, his parents felt less threatened by modality and because of the ability of music to circumvent words and create an alternative mode of communication.

The intake process in Developmental-Integrative Music Therapy (Sekeles, 1996) mainly entails spontaneous and/or planned observation of musical activity according to certain scales of development. In Danny’s intake, he initiated a war between a big drum and a cymbal, just a few minutes after he entered the clinic (1st recorded example: War between the drum & the cymbal). At the end of his percussive experience, he commented: “The good cymbal defeated the bad drum, but they won’t be friends, neither will they play together”. This was the first meeting, and the first time Danny expressed splitting by using two musical instruments in a symbolic way, and portrayed an emotional condition through music. Over the 3 years of therapy that ensued, we worked through this issue which had clearly divided his entire world into black and white. Working through involved music as well as speech.

Improvisations, as well as “Clarification, verbalization and interpretation, used consistently, reduce anxieties as they arise, dissolve crippling defenses before they become pathogenic, and open up, or keep open, outlets for drive activity which bring relief” (Anna Freud, 1965: 218).

Splitting, as analyzed by Melanie Klein (1986), can involve both the object and the ego. The earliest splitting between the good and the bad self, and between the good and the bad object, serves as a primitive ego mechanism and defense against anxiety. In cases where splitting and disintegration occur too frequently, the child is liable to develop emotional problems, as seen in Danny’s case. During the elaboration process’s it had become obvious that Danny had aggressive fantasies toward himself and toward his parents. When his anger was channeled into the physical action of drumming, he was able to achieve better organization and sublimation. Still, a long period of working-through passed before Danny could gain some insight.

Technically, Danny shifted his expression of splitting from the drums to other modalities, among which was drawings of his own self-image. First, he expressed “the bad me” (slide 1/slide 2) with the following explanation: “Me the wrecker. My eyes are shooting laser beams, my nose is sending a rocket and fire shoots out of my mouth”. Four months latter he drew “the good me” (slide 3) and said: “ I am a king with a crown and bright color’s dresses”. Though his self-image had begun to change and his behavior in school became less aggressive, Danny still suffered from isolation and lack of self-confidence regarding the role of his parents in his life. An example of this can be seen through guided imagery, when a musical piece

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called “The Golden Voyage” elicited the following image: Mother eagle is flying in the air carrying her two babies on her back. (slide 4). He explained: “The picture is from the land of scribbles and dreams. The two babies and their mother are flying through the air, never able to descend to earth. At worst, if the chicks are tired they can rest on their mother’s back, that is if she agrees to slow down a bit". Here Danny expressed his wish to descend to a safe place and his difficulty to accept his mother’s unpredictability. The Golden Voyage served as a facilitating factor to elicit and control fantasies.

Presented here was one of many examples of the phenomenon of splitting as appears in music therapy.

B. Healthy Gentle expression In Danny’s case, I would like to illustrate his ability to express a gentle compassion, even during the period in which he was extremely aggressive. It gave me the feeling that within the Devil-Danny there was another Danny, compassionate yearning to love. An Angel-Danny. This happened during the same intake that Danny staged the war between the drum and the cymbal. After listening to his own recording, he improvised a “praising song” (2nd recorded example and).

The winning cymbal: D. Yes, the cymbal won, It won over the bad and that is that.

T. Your song is beautiful.

D. Many thanks.

T. And your voice is pretty.

D. So are the flowers (Intake).

Another example of tenderness was shown by 16 years old Gad, who was addicted to drugs and glue, and suffered from uncontrolled anger which caused him to perform dangerous actions. Gad had lost his mother and sister in a car accident while he was 9 years old. He remained in an ongoing pathological mourning and did not react to verbal therapy. His relationship with his father and the rest of the family were disastrous and at the age of 14 he began to experiment with drugs.

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C. Denial

After half a year of hospitalization, Gad was released, tried to follow school but failed in almost all subjects, and was referred to music therapy by his psychiatrist.

Indication for the relevance 0f this referral was as such: Gad drummed on every possible object, he was “addicted” to trance music and was even allowed to listen to this music with earphones during class. This fact reflected his teachers’ desperation. During our first meeting, he drummed the huge table drum to death. The drum beater was broken into 2 pieces and he then suddenly turned to the piano (which he never played before) and elicited a gentle, tender tune using both hands (3rd recorded example: Gentle piano experiments after drumming).

In music therapy, Gad and Danny both demonstrated an ability unknown to their environment: the capacity to be gentle and the wish to diminish the inside turmoil which dominated their lives. In both cases it was possible to move from aggressiveness to gentleness, as the drumming enabled a sublimatory outlet, paving the way to hidden, tender feelings. For the therapist, it is mostly a very precious moment of enlightenment.

C. Denial As Anna Freud formulated it in her book: “The Ego and the Mechanism of Defense”, the task of the defense mechanism is to support the ego in coping with instinct anxiety, objective anxiety and conscious anxiety (Anna Freud, 1977). Anna Freud talks about the employment of denial in imaginative thinking. Indeed, children use denial in many ways, by transferring the origin of anxiety to something imaginative. This can be seen in the play of children, when they portray different roles, such as that of an animal, a hero etc. Denial can exist as long as it does not damage the ability to assess reality. When the ego matures and is unified by synthesis, there is no need to employ denial, unless there is a serious defect in the maturation process, as happens in psychosis. In the following example, we shall meet Didi, an energetic tiny girl, whose mother was killed in an extremely traumatic event, which left the family (father and 3 children) shocked and disheartened. At that time, Didi was 4 years old. Throughout the first months of music therapy, the child dedicated her time in running, dancing, singing jolly songs, laughing strangely, making sharp movements and resisting music that seemed sad to her.

That is to say: she could stand only very quick, rhythmic music (4th recorded example: text & melody improvised by Didi).

A spring song

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The flowers passed through the field and clowns jumped on the sun.

Stars glitter at night and the sun dances in the morning.

It is fun to be in the field, It is fun to be in the field [be=live, be alive] It is my nicest field: Many flowers, arches, clouds and very good rain.

For 2 months, her father stayed with her in the clinic (first inside and gradually outside the door) due to her enormous separation anxiety. Although Didi new all the details concerning her mother’s death, she refused to acknowledge the death emotionally and took care of eliminating and abolishing all signs of mourning.

After few months, Didi, who had never before touched the huge drum, discovered its value and began creating a short drum-ceremony at the beginning of each session. This drumming, which was heavy and dramatic, continued ever since, unveiling a deep layer of bereavement and fear of death. At the same time 2 additional events helped bring about change in the usual pattern of denial: the war in Iraq and an illness that caused me to loose my voice for several weeks. Didi, as most children in our country who live in an unsafe and unstable environment, was again frightened to death and asked me: “Chava when are you going to get a heart attack and die?” This question opened the rout to talk about her fears of loosing her father, brother and sister, grandparents and all the people she cared for. I quote: “I was told once that young people do not die, but it is not true: my mother was young, Giora was just 25, children died around me. One can never know and it frightens me”.

The loss of a parent influences child’s development and self-confidence. This is specifically true when it occurs before their identity has been formed and before the image of the parent has been internalized. In addition, there is a danger that it will elicit anxiety and fear of recurrent losses before the child has learnt to cope with the concept of death and the dramatic changes that follow. As therapists, we ought to observe the surrounding environment and judge its capability to contain the child’s anger and sadness. We should consider the child’s social difficulties as well as the parents-child interaction which characterized the before-death situation.

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D. Rationalization

Research shows us, that a child that experienced healthy, containing and supportive relationship, has a good likelihood of passing through the stages of bereavement and mentally rebuilding the lost parent’s image (Silberman and Worden, 1992a). In our case, the mental presentation of the mother. In accordance with Bowlby’s late theory (1969/1973/1980), in her choice of music, Didi first demonstrated the stage of shock and denial. Gradually, she passed on to a stage in which she musically experienced a healthy representation of frightening issues: how her mother was killed, how the Columbia shuttle with the Israeli pilot went down, medical pain treatment etc.

She experienced with these issues for several months till it became clear and less frightening. In her mother’s last memorial day she was able to recite in the cemetery a song she composed over her dead mother.

Didi has a supportive family. This may be one of the reasons why her emotional process in therapy is developing in a natural way, including the denial period, which kept her safe for a while until she was ready to cope with her deepest fantasies and anxieties.

D. Rationalization Raya lost her son many years ago in an accident during a time of war. In the first 2 years after his death she coped more or less with the situation though she showed less general motivation. Later, her husband passed away due to a terminal illness and she was left with her youngest son. At that point, her functioning deteriorated and she was treated psychologically and biologically. After a year, she was referred to music therapy by the psychiatrist of the place she had undergone 3 years of treatment at. Two years following the termination of MT she remarried a widower who brought his two daughters to the new family nest. Raya has undoubtedly rehabilitated her life. This is an outline of the story, but what had I observed through the intake process? An impressive woman, conservatively dressed, her movements somewhat sharp, her manner of talking was arrested and quiet, her Hebrew grammar perfect. Above all, she was very rational and careful not to exhibit any sign of weakness. She gave me few lectures in which she analyzed her psychological situation, almost professionally, but whenever she approached an emotional issue, she took care to circumvent it with mountains of rationalizing words.

In the case of Raya, at that time, both the past and the future were empty of content and the deficiency struck her and left her helpless. Rationalism worked for her as a

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defense mechanism and it took half a year before she could say: “I feel most of the time as if I am tied up to a coffin, as if I am also lying in the grave unable to breath.

I can not concentrate on my youngest son. Moreover, I even think that he does not need me”. This image opened a tiny window for working through, by exaggerating the feeling of suffocation and examining it in musical improvisations. Raya’s demeanor being so rigid, I suggested a simple improvisation on one note (5th recorded example: Tied up in a coffin). In this example, we can hear the E note serving Raya as an anchor and holding frame, enabling her to transmit and cast her own content safely: First monotonic and perhaps compulsive and gradually becoming more free and playsome. Play, in its most dynamic meaning as a creative component in our life and that did not exist even in Raya’s cooking. Throughout the years of therapy, Raya became creative and flexible in her musical expression, in her dance-movement and in her verbalization.

E. Passive-aggressiveness There are many expressions of passive-aggressiveness observable in music therapy.

I chose to show this phenomenon through the choice of the patients’ instruments: Jonas lost his mother through a long process of suffering, pain and helplessness, which soon manifested itself in passive-aggressiveness. During the years of his mother’s terminal condition, he was the naughty boy at home (from age 12 to age 16). He behaved as if mother was not lying there in severe pain, caused trouble in school, insulted his father, burned down his room and more. After his mother passed away, he became depressive, was expelled from school and from military service 2 years later. The army’s psychological service defined him as suffering from borderline personality disorder, but he refused to submit himself to psychological treatment and was eventually referred, first to art therapy, and then to music therapy. From the first stage of intake, he wanted to depict anger, not previously expressed, toward his dead mother who ”was lying there like nothing, nerving the whole family.” He chose a small lyre to depict his anger, and asked me to represent his mother on the piano, commenting: “My mother was dominant even in her last month”. Indeed, during many months of music therapy, Jonas kept choosing the most delicate musical instruments I have in my clinic to express anger (such as dulcimer, Japanese bells, lyre, baby steel drum etc). Progress in freeing himself from the ambivalent position and the feelings of guilt toward his mother, occurred when he was ready to use his voice. Beginning with soft vocalization, he became more and more daring, until he was shouting and vomiting all over (6th recorded example).

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F. Obsession

Passive-aggressiveness describes a behavior pattern in which aggressiveness is expressed by passivity, rather than activity. It is typical of persons suffering from low self-esteem and afraid that open aggressiveness will bring about revenge and damage, or even destroy them (Reber, 1985: 547). No doubt, Jonas was afraid from the negative feelings he had toward his dead mother, which could neither be accepted by his family, nor his community and above all, by himself. He first had to openly experience these feelings in the safe container of music therapy, and only then cope with it in real life.

F. Obsession I would like to present a short example of obsession as manifested itself in music therapy with Eric, a 40 year old schizophrenic patient in hospitalization. Eric showed many signs of obsessive-compulsive behavior. After two years of mute music therapy, during which he did not and probably could not utter a word, he gradually began to compose music and lyrics, after which he started to use his voice verbally and musically. His first song was divided into two sentences. After each, was a repeating sign with the number 20. Meaning, you have to repeat each sentence 20 times. â&#x20AC;&#x153;Pathological symptoms as far as rhythm is concerned find their expression either in extreme pedantry or in extreme flexibility. In the first case this means compulsive repetition and perseverance, whereas in the second case this results in disorder, disorganization and incoherence. Examples of extreme pedantry can be found among neurotics who make use of rhythm as a defense mechanism, as well as with psychotics who tend to enter into movemental and rhythmic perseverance (Sekeles, 1996: 37).

G. Cutting short the rhythmical end of a sung sentence This is a phenomenon I observed with schizophrenic patients and was recently informed that it exists also with other psychiatric patients (7th recorded example: An Israeli song). I spent a long time trying to understand the dynamics of this phenomenon, but could not find a satisfactory answer. However, Don, the patient you just heard, is a very musically-talented adolescent who plays from notes as well as

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by ear and has no counting problems. He also realizes that he sometimes cuts short the end of sentences, but mostly he can not overcome it. It is obvious that the underlying problem is not musical, but rather psychological. It might be connected to the loose associations, flow of ideas and speech, that typify the schizophrenic patient and makes it difficult for him to stay grounded in the “here and now”.

Indeed, many of them cut short also the end of the spoken sentences. (I would be interested to hear your opinion on this phenomenon).

Summary In this presentation, I have attempted to offer a few of the many examples which describe and analyze phenomena of health and pathology, as they appears in music therapy sessions: Splitting – as expressed by a war between 2 musical instruments and by self portraits and paintings of the patient; denial – as expressed by the choice of cheerful, not threatening music in the sessions of an orphan child who lost her mother in a traumatic event; rationalization – as expressed by a woman in a mourning process who helped herself coping by verbally rationalizing every step; healthy gentle feelings – as expressed by an extremely aggressive children, who surprisingly chose to display their angelic sides in music therapy; passive-aggressiveness – as expressed by an adolescent who was frightened to show his anger toward his dead mother; obsession – as expressed in music by a chronic schizophrenic patient; and lastly: cutting short the rhythmical end of sung sentences in well known songs.

All the examples were in the domain of music and from my point of view, they reveal the analogy between musical events and the inner world of the patients.

These analogies enable the music therapist to observe through music, diagnose, consider the therapeutic flow of the sessions and manage the treatment.

Bibliography 1. Bowlby, J (1969/1973/1980). Attachment and Loss. London: Hogarth Press Ltd. 2. Freud, A. (1965). Normality and Pathology in Childhood. New York: tional University Press.

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Interna-

Bibliography

3. Freud, A. (1977). The Ego and the Mechanisms of Defense (Hebrew). TelAviv: Dvir Co. Ltd. 4. Klein, M. (1989). Narrative of A Child Analysis. London: Virago Press (1st published by Hogarth Press Ltd. in 1975).

5. Reber, A. (1985). Dictionary of Psychology ( Hebrew). Tel-Aviv: Keter: 547.

6. Sekeles, C. (1996). Music: Motion and Emotion. St. Louis: MMB Music.

7. Silberman, P.R. and Worden, J.W. (1992a). Children’s reaction in the early month’s after the death of a parent. American Journal of Orthopsychiatry, 62, 63-104.

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Music Therapy Today, Vol. VI, Issue 4, (November 2005) a publication from MusicTherapyWorld.net

CHAPTER 53

Deep sound therapy

Saloheimo, Raisa

,INTRODUCTION TO DEEP SOUND THERAPY GENERAL

Where does the term " Deep sound therapy" come from? Iegor Reznikoff, Professor of Art and Music of Antiquity at the University of Paris, specialist in early music and especially and in particular the chant of Christian Antiquity, has been using the term since 1986 in his lectures and courses about the therapeutic influence of pure sound on various levels of human consciousness (advanced course of music therapy in Sibelius Academy).

To distinguish from the methodology used by speech therapists, I started to use the Finnish term "syv채 채채niterapia" (a direct translation from the English term "deep sound therapy "used by Reznikoff in his lectures).

Early chants of Christian Antiquity are sung with deep voice and contemplation, but the technique also differs from the familiar western style in its relation to notes.

In deep sound therapy we do not use the regular scale, but the natural scale where

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also the body resonates. The natural scale is often used in old folk songs, hymns and in church service in liturgical songs. Even tango music, which has achieved popularity in Finland, shows some similarity with the early church liturgical chants (modes) in the intervals. This is my personal opinion and for example professor Reznikoff does not agree with this idea.

BACKGROUND

I first made contact with the chants of Christian Antiquity in professor Reznikoff’s course in Sibelius Academy in 1987. Since then, I have used the methodology of deep sound therapy in music therapy and in lectures.

In 1989 to 1997 I mentored spring and autumn courses in Critical Academy of "The Experience and Understanding of pure Sound" together with Kirsti Autio, Tatjana Wilenius (in the start) and Hilkka-Liisa Vuori (a little later). I also used the methodology when I gave courses for vocational education students in music theraphy in Sibelius Academy 1990 to 1999. At each elementary course in music therapy I give a lecture and have a workshop.

In the summers I attend the courses of professor Reznikoff.

Since spring 1998 I teach singing of Christian chants of Antiquity in the Chapel of Mathew (Matinkappeli) in the Parish of Olari in the city of Espoo every second Friday evening. Singing skills are not a prerequisite for participation in the group. The natural scale in these songs and the resonation of the body while singing them help and support the singers to find their voices anew. In the group we also make therapeutic exercises.

In May 1998 this group sang of the chants at a church service in the Killinmäki institution for mentally handicapped. We continued in the autumn and since then we have taken part in their church service once a month. I feel that the service has improved during these five years. The service was mowed from the gym to the more imposing dining room and on April 10th 1997 bishop Eero Huovinen consecrated an altar on wheels for use at Killinmäki . With these improvements the amount of participants in the church services has tripled.

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DEEP SOUND THERAPY FROM A RELIGIOUS PERSPECTIVE

DEEP SOUND THERAPY FROM A RELIGIOUS PERSPECTIVE THE WORK WITH CONFIRMATION CLASSES

I have used deep sound therapy in parishes first in Espoo and later in Helsinki when teaching chants and giving music therapy in confirmation classes for mentally handicapped.

Comparing with the other religious songs, the advance of deep sound therapy is the way it settle down the target group. The voice affect also for the most anxious participants of classes and the ability to learn and participate increase significantly.

Since these songs represent the deep spiritual tradition of ancient Christian times, they are very physical ones â&#x20AC;&#x201C; the voice resonates in whole body and attain thus better also the consciousness/mental levels.

"A" [a:] as in arm resounds in chest, above the sternum and the heart. "O" [o:] as in moore resonates most strongly in the throat and can be felt through the spinal cord up to the limbic centre of the brain. "U" [u:] as in mouth resonates mostly in the mouth. "M" resounds in the whole head and can bee felt in the skeletal system of the body.

When you sing "A-O-U-M", the resonation starts from the chest, moves up to the throat and mouth ending in the head and above it. When you repeat it, the voice makes the resonation circulate in these areas and gives the singer "massage" from the inside. Breathing slows down and will automatically follow the rhythm during the song. The blood circulation and oxygen uptake in the brain and other parts of the body improves.

The syllable "OM"- is a holy syllable or mantra in Sanskrit and means God exist.

"A" is included when breathing in and "U" as a phonetic addition. "A-O-U-M" is repeated peacefully.

The Christian "Amen" is phonetically similar and has a similar meaning, "So be it".

Also the Jewish "Shalom" and the Islamic "Salaam" have the same kind of meaning. You wish peace with all your heart, speech and thoughts.

Singing is one of the best ways for severely mentally handicapped students in a confirmation class to get in touch music. Singing this way strongly resonating, they also make connection with the holy art of ancient Christian chants. In confirmation

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classes and in the confirmation ceremony the atmosphere is very concentrated, sentimental and concrete and your eyes are often close to tears. I can feel how strongly the students take part in the ceremony. For many of them it is difficult or almost impossible to talk or understand conversation, but hearing songs and singing is another matter and they are able to sing or try to sing some words or syllables such as "Amen" or "OOOO".

In Christian Antiquity the chants were prayers based on Bible texts, for example the Psalms. These antiphons touch not only the body but also the spirit and the soul – all levels of consciousness. In his early lectures Professor Reznikoff mentioned four levels of consciousness: Superficial, Medium, Deep and Divine consciousness.

The best way to pass on the Christian message, the prayers, to mentally handicapped is the chants of Christian Antiquity.

The impact of this kind of songs surprises and delights me again and again. And not only do they impress the students, but also me and the other attendees.

I can remember when I was at a concert by Professor Reznikoff for the first time. It was held in the church of Olaus Petri in Helsinki at the end of the course in February 1987. The winter afternoon was turning to evening and the church was lit only by candles. The song of Professor Reznikoff resounded and resonated in the darkness of the church. Sitting on the pew I felt somewhere between staying awake and falling asleep, but I still felt physically present. "My soul and my spirit was resting", and I can imagine that singers of Psalms through the ages have had a similar kind of experience.

My Father was a member of the Finnish Orthodox Church and often took me with him to follow the liturgy. My mother gave me a Lutheran education. When I was in the confirmation class I considered to convert, but I decided to stay Lutheran. Due to my background I am ecumenical.

SERVICE

The Ancient Christian chants add a special and strong influence to the divine service. These chants were an important part of services in the early Christian church.

The message sticks better when it is sung since the song passes through both sides of the brain and activates wider parts of it than the spoken word. The aphasics are good example of this; they are able to sing some old familiar songs accurately even though they cannot speak. The songs and the melody also help to understand speech (= melody intonation therapy). The songs in natural scale (human body resonates in natural scale) penetrates the different levels of human consciousness better than songs with western scale (temperated scale). To pray in a singing voice

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HOSPICE/TERMINAL CARE – ALLEVIATION OF PAIN

touches more deeply and calms one down. You get connection with your holy inmost. I do not know any other way that has such a so strong impact. This kind of song is a holy art. It takes care of not only the audience but also the singer herself.

We sang the Sanctus hymn at a church service in Killinmäki. One part of the group sang the borduna ( the base note) and the other sang the melody. After the service the priest and the cantor where surprised by the strong physical impact of the songs.

The priest said that he felt a resonation in his chest he had never experienced before. They did not sing themselves, but listened to the hymn of the holy trinity performed by our group (the deep sound group). We have sung in other services too, not just for mentally handicapped. The impact is always the same. It soothes the listeners.

In Matinkappeli we have a "church service time" once a month carried out by the laymen but following the liturgical form, except for the sermon or Holy Communion since there is no priest. In these ceremonies either I , or a part of my group, sings the antiphon that is appropriate with the topic of the ecclesiastical year.

Relatives of a departed mentally handicapped asked me to play zither and sing the songs, which were familiar from the confirmation class of the deceased about five years earlier. The ceremony was unique. Even though it was a stormy spring afternoon, the sun was shining on the casket just during the ceremony. The atmosphere was cordial and overarching. The presence of Holy was felt.

HOSPICE/TERMINAL CARE – ALLEVIATION OF PAIN Deep sound therapy eases the condition of dying persons in many ways. For example, a person in coma can hear the voices which penetrates all levels of the consciousness.

I will give an example of a man who was in a terminal care last spring. He was falling into coma and the nurses asked his relatives to come to say farewells. However, his sister could not make it there before he was in coma. The relatives and the priest asked me to sing for the dying man. I took my zither and we approached his bed.

The dying man’s wife asked us to sing a familiar hymn. I played my zither and sang together with the wife. Suddenly the man coughed, opened his eyes and started to sing with us. Then we sang the familiar hymn "Mun kanteleeni kauniimmin" and he waked up again and joined us in the song. He was also able to talk with his wife and

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sister. The doctor of our department was amazed: –"What has happened, he is supposed to be dead". The doctor asked the man in the sickbed if he would like to have something to eat but the man answered that he was not hungry. The relatives were astonished too, but happy to get to talk with the man once more. The pastor of our hospital said it was a miracle and very significant for relatives that he "waked up".

He lived one week after this event and had a peaceful departure.

The songs offer many dying people relief. A familiar hymn takes the thoughts away from the painful and depressing feelings. A beautiful and restful song concentrates the thoughts by consolation of the word (compare the idea of singing versus talking mentioned earlier). Songs in natural scale (that is most of the hymns and many other religious songs) affect also physically by resonating the body. The pioneer of music therapy in Finland, psychologist and music therapist Petri Lehikoinen, has developed the so called physioacoustic therapy which utilises low frequency sine waves to reduce stress and muscular pain. Originally the idea comes from the strong relaxing impact of music on the human body. One can say that the physioacoustic or vibrational energy treatment is like a machine massage and deep sound therapy is a manual massage.

A 40 year old women had breast cancer. It was operated and she received cytostatic treatment and radiotherapy. After a couple of months the cancer had extended to her brain and lunges. The cytostatic treatment was discontinued and she was told she had a couple of months or maybe half a year left to live. She was transferred to the health centre’s ward for terminal care. I met her in the emergency department where the doctor asked my consultation, thinking about music therapy. I went to her room where she was lying in her bed. The doctor and the assisting nurse where also there to follow the situation. The problem with her was occasional anxiety an confusion. After saying hello, I started to sing to her with a deep voice. She calmed down immediately, shut her eyes and looked as if she had fallen asleep. After five minutes of singing we left the room. The doctor was instantly convinced of the necessity of music therapy. Later the patient was transferred to a hospital nearer to my place and it was easier for me to help her daily. The second time I saw her she had a bright moment and told me what she had experienced when the first time we met. She remembered how I had sung for her and asked for more. She also told about her children and how difficult it was to part from her youngest, ten year old son. I recommended discussions with our hospital priest. In the following months she was occasionally confused and fastened to the chair or bed due to safety reasons when the staff was not available. I met her regularly, almost daily, and our hospital priest had discussions with her. Deep sound therapy always calmed her down and made her obviously relaxed. I also met her relatives and friends and they were grateful for the treatment. Obviously the terminal care of such a person is hard for

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HOSPICE/TERMINAL CARE – ALLEVIATION OF PAIN

the nurses and other staff, many of them were of same age as the dying woman or even younger. Her energy diminished gradually and she died peacefully with her relatives gathered around her. Deep sound therapy did offer help, along with sufficient medical treatment.

When my husband was in his deathbed in coma, he reacted strongly to noise. The noise from a landing field for helicopters near the cancer clinic caused him painful feelings. One night when he suffered from the noise it was replaced by the classical aria in Händel’s Rinaldo on the radio. The music had an instant effect and he calmed down. My husband loved Händel’s music and used to listen to it often when he was healthy.

Why does deep sound therapy affect so strongly? Deep sound penetrates deep into human body. For example, the singing of "OOOOOO" affects through the spinal cord on the limbic system of the brain and the hypothalamus and from there on the autonomic, previously named vegetative, nervous system.

"The autonomic nervous system is part of the peripheral nervous system, which controls the smooth muscle tissue, the heart and the glands. It is also named the unintentional nervous system.

The hypothalamus activates the sympathetic nervous system, for example in physical or corporal work, in dangerous situations, strong emotional feelings and other kind of stressful situations. The limbic system connects the autonomic nervous system with emotional experiences"( 1). Hence songs calm down and balance nerves and brain. The effect can be strong enough to make an epileptic fit disappear. I have had several experiences about this in my practice. An epileptic fit is a malfunction of the brain and sound, specially the "OOOOO" makes it stop.

Deep sound therapy even has cumulative effect on some people. One singer in my group suffered from severe epilepsy. She sang in the group, one and a half hour about every second week. Later on she told me that after one of these singing sessions she had no epileptic fit for even two weeks. Naturally, she had medical treatment as well.

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AUTISM AND THE USE OF DEEP SOUND THERAPY For about nine years in the 1990s I rehabilitated children who were diagnosed autistic. Deep sound therapy offers the best possibilities to get good results. Music as such is pleasing for most of the children. Deep sound therapy made it possible to get contact with them and to get a message through by singing.

One child immediately stopped walking around and stood still when I started singing. He stayed almost frozen and stared at me, probably wondering where the voice came from.

Most children had very sensitive hearing, which caused them difficult situations.

For example, the noise from the air conditioning might sound as the noise from the a jet plane and cause even insufferable pain. In order to achieve successful therapy the room had to be emptied from all extra things.

For many of the children diagnosed with autism the visual messages and visual perception offers the base for assessment of the situation. They do not necessarily understand spoken language. Therefore I use visual hints such as pictures of situations, items and actions to illustrate the daily routines from their point of view (so called pictos). The music therapy is also divided in separate themes with the help of the pictures. Clear start, intermediate phase and end state. In order to achieve relaxation in the end state I used deep sound therapy. At the start I sang each name in natural scale (for example "Is Maija here" in the melody of the hymn Hosanna filio), and they answered in there own way, even singing or playing some rhythm instrument. I was called "Auntie OO" by one kid, which described well the matter I was representing.

I observed obvious progress in interaction skills, concentration capabilities and communication skills. The children’s taste of music also expanded. For example, one girl who was in my rehabilitiation four years unexpectedly took a CD disc and started to listen. Her mother wondered what her daughter was listening to with earphones and noticed that it was one of Sibelius symphonies The girl enjoyed that CD for a long time. Before that her only music used to be children’s songs. Her capability to tolerate different kind of sound improved. Her learning improved the longer the rehabilitation continued. Special features of her behaviour did not disappeared, but they did not disturb as much as earlier.

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AUTISM AND THE USE OF DEEP SOUND THERAPY

The aim with most of the children were to get them into dialogue, to communicate, concentrate and express themselves. We also tried to develop social skills. Earlier, about 10–20 years ago, there was a view that autism is an early disturbance in the child–mother relationship, but hat view has later been proved wrong. Autism is a serious neurological problem which can not be cured with traditional psychotherapy. Because of this neurological background, music therapy and specially deep sound therapy are good rehabilitation methods. Mentors with psychotherapeutic background said that autistic children have no social contact skills. I think it is wrong to think that way, because my experience of working with them tells me quite different. The traditional music therapists rehabilitated earlier autistic children only with individual therapy, very seldom in groups. In the 1970`s Juliette Alvin and Auriel Warwick in their book "Music therapy with autistic children" (translated

by Kari Riikkilä 1995) reported only of situations where the music therapist and child were working together. In some cases the child’s mother joined in the therapy after a while.

I always started the music therapy with autistic children in a group because their problems mostly appear in group situations and that is why it s better to start the therapy in a group. Very seldom I had individual therapy with them, only with a strong reason, for example a difficult behaviour problem such as aggression against to other members of the group. Then I worked with them individually but the goal was always to get them back in the group.

This same mechanism explains the behaviour of an autistic person during deep sound therapy. The sounds are directly connected with the autistic persons world because. Words can for example be more easily understood when melody is added.

The spoken language does not penetrate the consciousness of the autistic person ("Taide psykososiaalisen työn välineenä", pages 143–144, edited by Heidi AhonenEerikäinen). Temple Grandin, who is an autistic person herself, mentions in her book "Out of autism" how decisive all communications therapies such as speech and music therapy was to her. I mentioned above the neurological influence on the limbic system of nerves and hypothalamus. In the their book Neurology (page 52) the authors Jorma Palo, Matti Jokelainen, Markku Kaste, Heikki Teräväinen and Olli Valtimo shows a picture of the structure of the autonomic nervous system.

Also in Parkinson’s disease deep sound therapy calms down and relaxes with remarkable effect on the forced movements the patient is suffering from.

I have tried to give a picture of the use deep sound therapy with some examples so that the reader can get a better view about what it is like working with autistic children with difficulties in communication and behaviour. There are very few books

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about this problem. However I have got support from T.E.A.C.C.H.(Treatment and education of autistic and related communication handicapped children), a method I learned and from psychologist Tuula Kulomäki in the Autism Unit, who mentored in our team. Working with autistic children themselves gave me the best knowledge. When I became acquainted with their world, how they see it, it was a very learning and interesting experience. It was amazing how much curiosity, patience and toleration the showed the music therapist who was quite lost every now and then.

Acknowledgements I am very grateful to Professor Iegor Reznikoff for his numerous lectures and courses where I have got an opportunity to learn DEEP UNDERSTANDING AND EXPERIENCE OF SOUND. Partly, I could use his method quite direct, but I have also developed it with my own point of views. Most I rejoice that Christian chants of Antiquity have enthused so many people in Finland to sing and learn these songs.

REFERENCES 1. Professor Reznikoffs lectures in Sibelius Academy on different courses 1987– 2000 2. "Taide psykososiaalisen työskentelyn välineenä", Heidi Ahonen-Eerikäinen (Ed.), pages 141–144, 147–150. Pohjois-Karjalan ammattikorkeakoulu. Joensuu 1994.

3."Neurologia", Jorma Palo,Matti Jokelainen, Markku Kaste, Heikki Teräväinen, Olli Valtimo. WSOY 1988.

4."Autistisen lapsen musiikkiterapia", Juliette Alvi, Auriel Warwick, translation Kari Riikkilä 1995. Kehitysvammaliitto

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Music Therapy Today, Vol. VI, Issue 4, (November 2005) a publication from MusicTherapyWorld.net

CHAPTER 54

The development of a schools music therapy service with an illustrative

case study of work with a child with Autism

Storey, Jo

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The development of a schools music therapy service with an illustrative

This paper was presented at the 6th European Music Therapy Congress in Finland in June 2004. It was illustrated with video extracts, and for the purpose of this paper I shall write a description of the extracts.

Introduction – Music Therapy in Cambridgeshire Schools I would like to begin this paper with an over-view of how music therapy came to be established in schools in Cambridgeshire, UK. Within the paper I am also going to present aspects of music therapy work in schools, illustrated by a case study of work with a boy with autism.

In 1995 there was no organised system for music therapy in schools in Cambridgeshire, and very little practical work in existence. Amelia Oldfield was working with pre-school children at the Child Development Centre at Addenbrookes Hospital and with school-aged children at the Croft Children’s Unit, but there was hardly any music therapy provision in schools.

At this time the first intake of music therapy students completed their training at Anglia Polytechnic University, and Helen Odell-Miller and Amelia Oldfield (the course leaders) had initial discussions with Martin Gent (then head of Cambridgeshire Instrumental Music Agency) about the possibility of setting up music therapy in schools. The Cambridgeshire Instrumental Music Agency (CIMA) was responsible for supplying peripatetic instrumental teachers to mainstream schools in the area, but had not previously had any links with music therapy. Martin Gent consequently wrote to all the special schools in the area and there was considerable interest in this. Initially CIMA took on three music therapists to cover a few hours here and there in a variety of special schools.

Over the last nine years the team has expanded to 8 music therapists working in a number of different special needs and mainstream schools. Generally the work has developed by music therapists starting off working for a few hours in each school, and once the school becomes convinced that music therapy is effective and therefore essential, they expand the hours (and somehow manage to find the money in their restricted budgets….!) This has happened in virtually every school that CIMA music therapists have worked in.

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Fitting into the school context

There have been many advantages to the creation of an organised system of music therapy provision in the county, in conjunction with CIMA. At the out-set we were able to set up a Service Level Agreement, which presented the needs of the schools and also the working requirements for music therapists, for example, instrument and room provision, the need to have breaks between sessions for writing up notes, and so on. This meant that music therapists setting up work in schools had these guide-lines to work from, and both schools and therapists had similar expectations for the organisation of the work. In addition to this, a fair system of pay and travelling expenses was established. Music therapists are paid on a percentage salary by CIMA according to the number of hours they work per week. The schools put in an order for the quantity of music therapy hours they require for each academic year.

It has been exciting to see the team developing and evolving over the years. Being under the CIMA “umbrella” has meant that the work has remained consistently organised, and that we have met regularly as a team, both to discuss work issues and socially. This has avoided the isolation that music therapists can experience when travelling around from school to school. CIMA has provided funding for inservice training days, and we have been able to consider each team members professional development.

Fitting into the school context I feel that our main strength as a music therapy team has been the capacity to be flexible and adaptable in relation to each different school environment. Some schools have been extremely limited in terms of providing a space for therapists to work in. In this case we have taken the approach that we can work for a short period of time in a space which may not be ideal. Once positive relationships with staff and children at the school have become established it has then become possible to suggest the need for a more appropriate working space. In our experience it has been better to work in this way in conjunction with the school, than to immediately demand the impossible! Generally if schools have the experience of a therapist working on site they become aware of the requirements of the therapist, in terms of space and instrument provision, over a period of time. The essential factor has always been positive communication with staff at the school.

To quote from Leslie Bunt and Sarah Hoskyn’s book “The Handbook of Music Therapy”(2002):

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“Several authorities in the UK employ music therapists………The settings where children are seen for therapy vary from dedicated spaces in music therapy centres to shared spaces in pre-school nurseries and rooms of varying quality in schools.

The provision of suitable space for therapy is usually improved when there is a clear explanation about the work and close liaison between the visiting music therapist and other staff in these settings.”

Every four years schools in the UK have to undergo a schools inspection by Ofsted inspectors. These inspectors took over the role of schools inspections about 9 years ago. Music therapists working in the school context have to communicate with the inspectors about their work, and on occasion, provide music therapy sessions for observation. In my experience this has been a surprisingly positive experience, despite my initial reservations…! In all three inspections I have experienced, the inspectors have pre-arranged some appropriate music therapy observation and have been very sensitive to the nature of our work. The last time an Ofsted inspector observed a session it culminated in positive feed-back within the schools report, and this in turn led to an expansion of my hours at the school. The inspector had not previously observed any music therapy but was a musician, and appreciated the powerful effect of music on the children!

I should probably discuss the difficulties of setting up work as well as our positive experiences….. It is hard to go into a school where music therapy has not previously been established. Colleagues at schools can be very suspicious of “therapy” and there may also be jealousy of the fact that we have the opportunity to work oneto-one with a child. Again we have found that honesty and openness is the best policy. Talks for staff and sharing video material (where appropriate) can enable colleagues to understand the work, and to view it in a positive light. We aim to work as part of a team within each of the schools, even when working for just a few hours in each school. The more discussion of work with staff that takes place, the more this is possible. Regular meetings with teachers, learning support staff and other therapists are essential as a means of sharing information about children and facilitating a team approach.

Auriel Warwick(1995) described the need for communication with staff in schools in her chapter on the development of music therapy in education in Oxfordshire: “Music therapists must take on the responsibility for dispelling…suspicion and anxieties by being open about their aims and methods: talking in seminars to colleagues in schools, school governors, running workshops and presenting videos of individual and group work with children so that the value of the therapy can be seen in the context of the whole curriculum for the child.”

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Case Study - Christopher

We have found that this positive type of publicity, promoting understanding about music therapy has been invaluable.

We regularly have music therapy students from Anglia Polytechnic University on placement at the schools and provide suitable music therapy sessions for students to observe, as well as setting up case work for them. The little boy, Christopher, I would like to discuss had music therapy sessions with a music therapy student, Ioanna Etmektsoglou, for two months, prior to my commencing work with him.

Ioanna was on placement with me at Green Hedges School during this time. She observed some of my work over this period and carried out her own case work. I supervised some of her case work, and this provided me with information as to how children were progressing in sessions. There was also valuable dialogue between Ioanna and the class teachers and learning support assistants.

Case Study - Christopher Christopher was six years old and had a diagnosis of autism. He had a history of tantrums and challenging behaviour in relation to feeling a loss of control, and also limited communication and no speech when I first met him. He was a child who I feel particularly benefited from having music therapy within his school environment. He was bright and alert, but had extreme problems with dealing with new or unpredictable environments which he felt were beyond his control. By first becoming familiar with his class room setting, he was able to build up his confidence to moving to the music therapy environment within a relatively short period of time.

The music therapy room was just down the corridor from the class, and it was therefore not too traumatic for Christopher to make the move to this space. Had he had to travel somewhere else for the sessions it would have been much more disruptive.

Christopher initially presented as a very nervous child who needed to literally cling on to things for support. He was desperately in need of reassurance both in and out of music therapy sessions. However, during his 2 months of sessions with Ioanna it became clear that he was very responsive and sensitised to sound and music.

Through his interest in the musical instruments his confidence began to increase, and he would sit very close to Ioanna, tentatively exploring the instruments.

Ioannaâ&#x20AC;&#x2122;s gentle and calm manner enabled Christopher to feel relatively secure within the music therapy environment, and she introduced him to some new songs, playing along quietly with smaller musical instruments. At the end of this phase of

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therapy Christopher had built a positive relationship with Ioanna based on the shared experience of quiet playing and singing together.

Ioanna was keen for Christopher to continue to have music therapy after she finished her placement, and I resumed music therapy with him the following September(2001).

One of the points that Ioanna and I discussed in relation to Christopher’s sessions was his love of familiar song material and the structure that this provided for the music therapy. The first video extract I presented was of me singing a hello song with Christopher which provided this element of structure and preparation for the start of the session.

The video extracts were taken from a session after I had been working with Christopher for a year and a half. By this time he was taking a relatively confident approach to playing and exploring the instruments, and was also enjoying using his voice.

For the first year of sessions Christopher used to just listen to the “Hello” song, but as his confidence with his singing and vocalising developed he became able to sing along with me. In the extract Christopher was extremely engaged in the content and familiarity of the song, and put his head down to listen at the same time as vocalising along. His vocalising was tuneful and consistent, and became increasingly confident as the song progressed. This reflected Christopher’s developing confidence in the use of his voice in music therapy, but also in other contexts.

In the video extract you could see Christopher pressing down the piano keys repeatedly and this seemed to add to his sense of control. Christopher often did this when I was accompanying him on the piano. At times he would hold the ocean drum in one hand, and press the piano keys with the other.

Chistopher was generally avoiding eye contact even though he was totally absorbed into the shared singing experience. In fact, the most sustained eye contact he used was generally in response to a sudden change in pitch or rhythm, so I was able to use this to encourage a more consistent exchange of eye contact.

Another aspect of working in a school is the need to have an awareness of the child’s experiences in the class setting. At Green Hedges School, where I am based, they use a structured approach to working with children with autism, called the TEACCH method. This is a system whereby the child is very involved in the structure of the day. He/she will have a time-table with symbols or words for each activ-

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Case Study - Christopher

ity during the day. With this system, the child becomes prepared for changes in activity or environment, and therefore is less traumatised by these things. Each child I work with will have a symbol or picture for music therapy on his/her timetable for the day on which I see them. As well as engaging in this process, I often feel the need to incorporate an element of structure into the session itself, to help the child utilise the session with the minimum of stress. It is possible to create space for expression and spontaneity within a secure structure. Christopher was a child who needed structure within sessions, and would have found it very difficult to participate in the playing without this reassurance. With a predictable structure it was possible to draw Christopher into expressive shared playing and singing, which would have been too threatening without this safety net.

As I have discussed, the links with staff and parents at the school has been an important part of my work. I received a lot of information about Christopher’s development in other situations from staff at the school and also from his mother.

Christopher’s mother was delighted that he would be receiving music therapy at the school and was keen to discuss his development in sessions. She was able to inform me of his progress at home, particularly in relation to his use of his voice.

The next video extract was of Christopher and I engaging in shared singing and playing on the “frog” castanets. This was a song that Christopher and I had shared many times in sessions, and one that he enjoyed very much. It began with me singing with the frog scrapers and him playing along on the scraper too. Gradually he started to vocalise and this evolved over a period of months to him vocalising increasingly tunefully and then attempting to annunciate the words with the tune.

In the extract you could see Christopher looking around the room, constantly checking out his environment and making sure things were “safe”. At the same time he was remarkably involved in the music making process and sharing in the song material with me.

Through discussion with Christopher’s class teacher I established that he was using his voice increasingly confidently in the class room setting, and beginning to participate in group singing activities. I showed these video excerpts to Christopher’s class teacher and she was extremely impressed with the comparative confidence with which he used his voice in the music therapy room. This gave me feed-back on his vocal development in the class setting, but also enlightened the teacher as to the type of interaction that we were having in music therapy.

Christopher’s need to control his environment became apparent soon on. I had a guitar in the corner of the room which was leant against the piano. One day Christopher came into the room and immediately began screaming and pointing to the

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instrument. I realised that the angle that the guitar was leaning at was slightly different to the week before. I moved the guitar out of the room and Christopher relaxed straight away. After discussion with his class teacher I decided to have the guitar back in the room for the next session. It transpired that the policy with Christopher’s adverse reactions to things was to try and enable him to face up to objects or the placing of objects, even if they initially upset him. Sure enough, the next session he became very upset on seeing the guitar and had a tantrum for about 5 minutes. After this, he settled down and became focused on gentle playing on the shakers and drum, giving an occasional sob when he looked over at the guitar. The following week Christopher hardly noticed the guitar, and just ignored it. Over a period of weeks I managed to acclimatise him to the guitar, picking it up for a few minutes, and then putting it down when he became distressed.

After about a year of this, in weekly sessions, Christopher decided that he would like to play the guitar. He gradually put his hand closer and closer to the guitar strings, and eventually began strumming them gently. After a few weeks of this, he began to go and get the guitar at the same point in each session. He always gave me a triumphant grin when presenting the guitar to me. Over time I managed to establish some singing with the guitar which he enjoyed, and he was then able to relax and appreciate the sounds.

In the video extract you could see Christopher enjoying shared singing and playing with the guitar. His concentration was excellent and he was able to predict the ends of phrases to songs. Christopher put his hand out to control my playing from time to time, and this enhanced his sense of security within the interaction.

A very exciting development with Christopher’s sessions was his use of his voice.

He was verbally silent for the first few months of sessions, but always indicated to me that he enjoyed singing activities. Gradually he began to use his voice to make demands or respond to requests, making tuneful sounding “Hmm” or “Agah” vocal noises. As he became familiar with various songs that I sang to him, he began to vocalise along to them. This happened very gradually over a prolonged period of time. First of all his responses were tuneful and he began to imitate the pitch of my singing. Then he began to attempt to formulate the words as well as the pitch, making exaggerated confident mouth movements. Around this time Christopher’s mum informed me that he was beginning to sing to himself in his bedroom at home. He was more reluctant to sing when other people were with him, but he would sing to himself in bed! This gradually spread into other situations, and he began singing to his grandmother down the phone. Christopher’s mother now uses singing to calm him when he has adverse reactions to situations, and they also engage in some shared singing together.

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Conclusion

Christopher also became increasingly consistent and confident in his use of eye contact and gestures in order to communicate his needs.

Another area in which I discussed Christopher’s development with his mother and class teacher was his capacity to listen and concentrate on exchanges. Initially he was very easily distracted by his general levels of nervousness in relation to the environment.

In the next video extract you could see Christopher engaging in playing on the wood sticks, but also his listening ability. He began with confident, rhythmical playing and then his playing diminished by his need to listen to my flute playing.

You could see in the video extract that I tried to keep Christopher engaged in the music making by continuing to play even when he stopped. Through using this method his playing in other situations became more sustained. When he stopped playing Christopher still appeared to be listening, and made very direct eye contact as I finished the last phrase of my flute playing.

Christopher enjoyed choosing something to play good-bye on to prepare for the end of the session. In the next video extract he selected the wooden octachime. He initially played in a typically “autistic” type of way, focusing in on the physical elements of the musical instrument. We had a turn-taking structure for this activity, and when I had my turn I played in a more lively manner, but incorporated aspects of his approach to the playing. In this way I accepted his way of playing but also encouraged him to develop and expand his approach. When he had his second turn he was able to develop a freer style of playing, with some imitative elements of my contribution. This indicated that he was not “stuck” into an autistic type of play but was able to incorporate my ideas as well as retaining his own individual style.

Conclusion Christopher’s music therapy sessions provided him with a space in which to explore interactive and expressive playing in a secure environment, and to develop a confident and communicative approach to shared vocalising and singing. This led on to him being able to use his voice confidently and competently in other situations.

Christopher is just one example of a child who has benefited from having music therapy in his school environment. I haven’t had time to give examples of other children or other styles of my work at the school, but the possibilities for music

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therapy in this context are boundless. Within any special school the children have such a diversity of needs, and music making within a therapeutic context can be used to address these varying needs.

The case-study of Christopher high-lights the importance of music therapy being accessible to children within their school environment. Once children are established in a school setting it becomes difficult to incorporate music therapy sessions into the child’s routine, unless the music therapist is available on site at the school.

This is not only on the practical level of getting the child to the music therapist, but also taking account of the anxiety involved in the process of getting the child to a new place. There are increasingly high proportions of children with autistic spectrum disorder in special schools, and a large number of these children find going to new places a terrifying experience. By providing therapy on site at special and mainstream schools, children can learn to deal with the new therapy environment in a situation which is adjacent to their familiar school setting.

The possibilities of communication with staff and parents of children at the school greatly enhance the quality of the music therapy work, and as I have described, there are countless advantages to the therapist being able to integrate as part of the staff team.

Fortunately many schools in Cambridgeshire have risen to the challenge of securing funding for music therapy, and we hope that the team of music therapists working in schools in our county will continue to increase. I would also be delighted to see other county music services taking music therapy under their wing, so that the provision of music therapy in schools in the UK could become more evenly distributed and consistently organised.

References Bunt, L. and Hoskyns, S. (2002). “The Handbook of Music Therapy”. Bruner-Routledge Warwick, A (1995). “Music Therapy in the Education Service: Research with Autistic Children and their Mothers”. In Wigram, Saperston, West (Ed.), “The Art and Science of Music Therapy: A Handbook”. (p.209). Harwood Academic Publishers

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References

Jo Storey trained as a music therapist at Anglia Polytechnic University (APU) in 1994. She was awarded her Masters in Music Therapy in 1998. She lectured at APU from September 2000 â&#x20AC;&#x201C; July 2001. Since 1995 she has worked as a music therapist in special needs schools in Cambridgeshire. In September 2001 she was appointed Head Music Therapist for Cambridgeshire Instrumental Music Agency.

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Music Therapy Today, Vol. VI, Issue 4, (November 2005) a publication from MusicTherapyWorld.net

CHAPTER 55

Time limitation in psycho-dynamic music therapy - a focal music therapy concept (FMT)

Storz, Dorothea storz@mdw.ac.at

Introduction Nowadays the general duration of a therapy is predominantly determined by economical aspects. This means as short as possible, according to the motto: time is money. Many music therapists have to deal with a treatment that lasts for a few weeks or a few months only. This often results from time restrictions defined by the national health services already at the beginning of the therapy.

In addition to this more and more clients themselves expect a prompt improvement of a single well described problem. From a psychodynamic point of view, one has to be very sceptical about such attitudes because the therapeutic concept is based on exploration, understanding and insight. These principles imply the necessity of having enough time.

Also musictherapeutical principles are usually associated with long term perspectives. They are closely linked with preverbal experiences and developmental pro-

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cesses which also need enough time. Hence, we have to answer the questions of how we can deal with these contradictory aspects and for which clients such a concept can be of any help.

Asking this crucial question I was driven to develop a concept which does not only consider the psychodynamic principles of musictherapy but also the demands of a short time therapy. I am personally motivated through my work of the last 20 years at the department of rehabilitation in the psychiatric Hospital in Vienna (a specific therapeutic department without any regional restrictions of the patients being there).

The diagnoses/indications of the inward patients are psychoses, borderline and personality disorders. Relapse with auto aggressive behaviour, chronic course or even suicides are a permanent risk for most of the patients. The average amount of the inward treatment is 3 to 5 months, the most frequent amount of sessions is between 11 and 25 hours: TABLE 1.

1 – 10 11 - 25 26 – 40

56,8 % 43,2 %

hours = 22,7 % hours = 63,6 % hours = 13,7 %

male female

Music Therapy at the Department of Rehabilitation 45 % schizophrenic psychosis 41 % borderline -disorder; eating disorder 14 % depression, manic depression, personality disorder

18 % 82 %

group music therapy individual music therapy

As we can see on the table the percentage of patients who take part in individual music therapy sessions is quite high. This fact and the above mentioned circumstances have asked for a musictherapeutical short term concept for individual therapy. Therefore I have developed a concept called: focal music therapy.

For me, one of the most important parts was to integrate my approach - the psychoanalytically informed music therapy - and the existing concept of a systemic, aimoriented treatment strategy of the department where I am working. Nevertheless inpatient work is almost all the time confronted with time restrictions.

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The general psychodynamic approach

I have chosen a methodology which has already proven right within music therapy that is to say the hermeneutical approach which I am going to outline in the following paragraphs.

Nowadays it is common sense to integrate psychotherapeutical models into musictherapeutical concepts. This means that musictherapeutical principles are being deduced from the principles of psychotherapeutical models and that they are being explained and modified on their fundamental believes. And this is exactly what I did in developing this focal concept. I linked the theories of the psychodynamic short term psychotherapy with the musictherapeutical theory of ”specific doing”.

A very prominent role plays the ”Psyhodynamic Short Term Psychotherapy” by Strupp & Binder. (Both are American psychoanalysts and psychiatrists with a long lasting clinical experience.) Their concept is based on the original assumptions of the psychoanalytical short term therapy and also involves the needs of psychiatric patients.

The now discussed focal music therapy concept has been developed in 3 main steps mainly based on Strupp & Binder’s approach. The first step was to identify the basic principles of therapy. The next step was to make out the described principles in the psychoanalytical informed musictherapeutical literature. And the last and most important part was to link these principles and to translate them into musictherapeutical interactions.

But before we go into details of this focal concept it is important to outline the sense and understanding of the general psychodynamic approach within musictherapeutical work and to give you a brief overview of the historical development of time limited dynamic psychotherapy.

The general psychodynamic approach Psychodynamic is the basic model to explain psychological experiences in the psychoanalysis resulting from a dysfunctional drive development which has its origin in deficits during childhood. The psychic processes are formed by the play of the different psychic forces which work together to support, to suppress, to combine, to conflict or to compromise with each other.

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Knowing this it is possible to understand the intrapsychic patterns of conflicts appearing during the musictherapeutical improvisation (resulting from common creative processes).

Therefore it is always the aim of psychodynamic oriented musictherapy to discover the structure of conflicts. In order to understand the past and the pattern of conflicts it is important to understand the structure of the intrapsychic processes, the phenomenon of transference and counter-transference, the defence and resistance.

These are some of the general principles which play a dominant role in every psychodynamic work and which are of course part of the FMT concept.

Historical background of the psychoanalytical short term therapy It is interesting that the literature of psychoanalytical short term therapy refers to famous musicians. Bruno Walter1 for example who asked Freud to care for his neurotic paralysis of his arm and which Freud should have treated in 6 sessions.

Another one was Gustav Mahler who also went to Freud and whose treatment took four hours in one session only.2 This fact – Freud’s partial interest in a kind of brief therapy at that time is an interesting fact insofar as Freud had to justify the increase of treatment duration at the same time (which was caused by changing the technique: analysis of resistance and transference).

As a reaction to this tendency Sandor Ferenczi and Otto Rank tried to shorten the length of the whole treatment. They did so by limiting time and intensifying the affectivity in the countertransference through establishing the ”Active Technique”.

1. Walter, Bruno. “Thema und Variationen.” Frankfurt a. M.: S. Fischer, 1947: 212–216.

2. For Mahler‘s and Stekel‘s treatments look Weghaupt 1998: 197.

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Historical background of the psychoanalytical short term therapy

TABLE 2.

Historical background

The Beginning of Time L imited Psychotherapy Proponents

Motivation

Method

1920’s

Ferenczi, Rank

Shortening the psychoanalysis to a more flexible treatment

„A ctive Technique“

1940’s

Alexander , French

Shortening the psychoanalysis to a more economic treatment ! a focused therapy for traumatized soldiers

„C orrecting emotional experience by regulating measures“

1950’s 1960’s

Balint, Ornstein, Ornstein and Malan

Independent shor t term psycho therapy concept: ‘The Focal T herapy ’ for a more economi c treatment

Mobilization of a conflict through the focus

As we can see Sandor Ferenczi and Otto Rank had been one of the pioneers and afterwards Thomas French and Franz Alexander from the States (USA) took up this initiative again whereas their motivation was to develop a proper concept especially to treat traumatized soldiers.

Michael Balint and the English Group have for the first time developed a concept for short term therapy on its own in contrary of shortening psychoanalysis. Afterwards a lot of different concepts have been developed since than. 5 of which I’d like to outline quite shortly.

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TABLE 3.

Psychodynamic Short Term Therapy Concepts

Psychodynamic Short Term Therapy Concepts Some Examples Balint, Ornstein, Malan & O rnstein

Linking interpretations between transference

experiences and f amiliy

constellations in the childhood

[ca 20 h] H . D avanloo

Working on

[ca 15 -30 h]

constellation

P. Sifneos

Defining an oedipal focus. The countertransf erence is meant as a disruptive

[ca 12 -15 h] J. Mann

factor.

Emotional conflicts as a result of the fight between unconscious desire for

[12 h] Strupp & Binder

endless love and care and the knowing about finiteness Defining a dynamic focus:

[ca 25 h]

Transf erence r elation Actual life situation

resistance

and

interpretation ref erring

to

early

f amily

Life history

And we are going directly to the psychodynamic short term therapy of Hans Strupp & Jeffry L. Binder and the question: Why exactly do I refer to their concept?

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Historical background of the psychoanalytical short term therapy

TABLE 4.

Motivation :

Strupp & Binder: The Psychodynamic Short Term Therapy

- A meanin gful c oncept for more patien ts - A concept for patients with h eavy ego function disorder s

Main

- In th e m iddle of inter est: the tr ansfer ence relation

Character istics:

- The qu estion: h ow do behaviour patter ns, resulting from ear ly exper iences influence actual r elationships - On this basis a dynamic focus is form ulated - Hypothes is: actual emotional distur bances and interpersonal problem s ar e a product of histor y _ Reconstr uc ting the past an d m aking r epr essed memories conscious are not part of the therapy

Indic ation:

- Possible for patients wit h heavy ego function dis or ders

Duration/

- Ca. 25 sess ions, 1 session per week

Frequency:

- Time limitation is set, when th e focus is formulated

The basic ideas of Strupp and Binder go very well with the musictherapeutical demands because of its interpersonal approach which means that the human relationship is of central importance.

The focus of the sessions is not on the reconstruction of the patient’s life story or on making repressed remembrances conscious but on the awareness of the patient’s enactments of his neurotic conflicts in the therapeutic relationship. (Thereby memories of the past are being involved and they are being connected to the whole life story.) The demand is ”to clarify the manner in which anachronistic beliefs, wishes and fantasies complicate the patient’s interpersonal relations in the present”3.

The assumption is that the therapeutic relationship is based on the fact that two people take part in a structured interaction. Both of them perceive this relationship 3. Strupp/Binder 1984:26

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from different and dependent perspectives. The behaviour and the attitude reflect these perspectives of which both the patient and the therapist are influenced.

Working on the relationship between the patient and the therapist is the main focus of the therapeutic effort. And exactly this concept of the therapeutic relationship allows us to understand the musictherapeutical activities and expressions and it helps to understand the way in which the therapist takes part – meaning the therapist’s actions and reactions.

As all of us know the therapists activity (action and reaction) – which I will describe in detail later on - is a very specific characteristic of music therapy working with improvisation.

After the overview of the sense and understanding of the general psychodynamic approach and the historical development of time limited dynamic psychotherapy we are now coming to the Focal Music Therapy Concept.

Focal Music Therapy TABLE 5.

Focal Music Therapy

Focal Music Therapy

main therapeutical components o

indication an d pr econditions

o o o

goal tim e musictherapeutic stance

o o

tr ansference and counter tr ansference dynamic focus

o o

defence and r esistance music an d experiencing music

o

musical m ec hanisms of effectiveness

o o

tech nique and in terventions a psychodynamic musictherapeu tic m odel of understan ding

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Transference and countertransference.

The main psychodynamic musictherapeutical components which are also key components in the focal work are: indication, goals, musictherapeutical stance and attitude, transference, countertransference, defense and resistance, technique and interventions, time, experiencing of music and musical mechanisms of effectiveness, and as specific components of this concept the work with a dynamic focus and a psychodynamic musictherapeutical »model of understanding«.

Some of them I am going to describe and especially the importance in focal working.

The presumption of the concept is a 2 to 4 month duration of inpatient or outpatient treatment with an average frequency of 10 to 25 hours of music therapy. Whereas I have developed the concept working with psychiatric patients it does not mean that it can only be applied for those patients.

INDICATION

The indication depends on the willingness and the capability of the patient to work on his emotions and conflicts in the therapeutic relation at least basically. It also depends on the assumption whether a main problem can be defined, whether it should or can be treated with musictherapeutical techniques and whether it is possible within the limitation of time.

AIM

The aim of this focal work is to experience, to understand and to work on early unfinished interactions. Thus the patient is able to develop new and ”better” relation qualities and living strategies in general. The personnel aims of the patient which are agreed between the patient and the therapist at the beginning of the therapy have to be linked to the early unfinished interactions.

Transference and countertransference.

The understanding of transference in this concept has to do with the fact that the patient is selectively attentive to a single aspect of the therapist’s musical behaviour and personality; that the patient is forced to choose one set of interpretation rather than others. His emotional life and adaptations are unconsciously governed by the particular viewpoint he has adopted and mostly important that he behaves in such a way as to bring out reactions that fit with his viewpoint and expectations.4

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Countertransference in these terms means (referring to Kernberg) the following: ”Through conscious and unconscious modes of relating, the patient evokes in the therapist internal affective reactions that symbolically represent facets of the patient’s internal world. The therapist’s reactions to this stimulation may directly reflect the patient’s conscious and unconscious wishes or other aspects of his or her self-experience, or they may reflect disavowed aspects of the patient’s self-representations and object representations.”5 In this sense countertransference allows us music therapists through musical interactions to take part in the inner life of the patient. To interfere in this sense and to cause changes is influenced by different factors which themselves need special attention.

Defence and resistance As you may guess right from the beginning it is necessary to take the defence as an intrapsychic phenomenon and resistance as an interpersonal phenomenon into consideration.

The musical interaction is an opportunity to understand and to hear the defence and the emotions behind it through the audible musical shape. Afterwards it is possible to make it understandable for the patient – slowly and softly – again through the musical shape.

Central questions in the musical interaction are: What is the unconscious intention in the musical interaction? What does the patient do to avoid reaching his aim? And how does the patient motivate the therapist to follow him?

But first of all we should ask questions like: what does the patient need to be able to use the musical interaction in a music therapeutical sense. Answering this we have to deal with the musictherapeutical attitude.

4. Strupp/Binder 1984:145 5. Kernberg 1980 in: Strupp/Binder 1984:147

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Music therapeutic attitude

Music therapeutic attitude Music therapeutic attitude means the musical way of transforming qualities which can be assigned to a therapeutically attitude; qualities which can be described as unspecific mechanisms of effectiveness. I have already discussed this in my publication of 19966 based on CIOMPI – who describes the therapeutic attitude qualities which have a favourable influence on human development in general.

These qualities are:

• • • • • •

quiet and calmness simplicity and lack of ambiguity dependability and continuity trust and directness tolerance authenticity

In this context »quiet and calmness« is to be understood as short, clear and calm musical motifs based on a calm metrum.

Or in the case of getting faster there has to be an appropriate metric and rhythmical accent like half of the tempo. »Simplicity and lack of ambiguity« can be realised by using clear and comprehensive rhythm, tonality and melody sequences. »Reliability and continuity« can only be communicated perceptibly by musical presence so that the therapist is becoming a real partner in a real dialogue as well as in a symbolic dialogue. This can be realised by a stable and ”going-with” metrum” (vibrating) or by repeating motifs.

Another possibility is to wait for ”the come back” which means hanging on to the original rhythm and tonality. With this aspect I want to emphasise the necessity of not following every single deviation.

6. Storz, D. 1997: 118-120

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»Trust and directness« are understandable by musical support, accompaniment and by strengthening. In addition to this it is important that you do not surprise or provoke unreflected or to use ”musical tricks”. In other words it is a straight foreword musical approach in which the created musical expression of the therapist is understandable. »Tolerance« means that every possible expression is to be accepted. This means to respond to the musical language of the patient and to follow some deviations resulting also from not being used to play an instrument. »The authenticity« is to be seen in the context of a symmetric musictherapeutical relationship in which we act as real partners in a nonverbal play. If the authenticity does not exist, all the other qualities are unbelievable and without effect.

These general musictherapeutical principles should create the condition to develop something unique for the patient himself.

Developing more security and an increasing musictherapeutical relationship are preconditions to make the patient interested in his own ”relation-experience” and ”relation-behaviour” within the musical interaction.

By using the above described principles we create enough space and possibilities for this process.

(Some of these qualities have already been described in Kenneth Bruscia's Book "Improvisational models of music therapy" (1987, Springfield, Illinois, USA: Charles C. Thomas Publisher).

Strupp & Binder also give the therapeutic stance a prominent role and they have formulated 25 principles of the therapeutic stance. What I did was to check if they can be used for the music therapy, completed them and made a list of musictherapeutical attitudes.

To give you an example I’d like to outline some of these principles

• From the very beginning of the musictherapeutical process it is important to

explain the possibilities, the sense and the procedure of the common music therapeutical work as well as the handling of the instruments – and this in an every day language.

• It is also important, to explain that the common work and the therapist’s support for the patient consist of taking part in his/her inner life through improvisation

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Musictherapeutical techniques and interventions

and therefore understand his/her musical expression and the kind of relationship he/she initiated.

• Another principle is that the therapist should not interrupt or stop the common

improvisation until he/she understands what the patient is trying to communicate. Right from the beginning we have to stimulate the patient’s curiosity and interest in him/herself and in improvisational collaborating with the therapist.

• The verbal language and the musical language have to be understandable and should correspond to the every day language.

• One more key issue is not to interpret every improvisation like being omniscient but to describe the musical and dynamical qualities and to complete with questions step by step.

• Interpretations only make sense and are helpful at a later time.

Such principles of a musictherapeutical stance are really helpful to work clearly and understandable with the patient and they are also a basic of musictherapeutical techniques and interventions.

Musictherapeutical techniques and interventions ”Musictherapeutical techniques are being realised in the conscious combination of psychotherapeutical techniques like holding, mirroring, confronting, interpreting a.m. and the specific use of musical elements like metrum, rhythm, timbre, tonality and dynamic.”7 (Storz, 1999) The techniques which are used in this concept are mainly: support, containment, exploration of the musical interaction, questions to understand the experienced, incorporation or the use of material from outside the therapeutic relationship (themes, dreams, problems with other persons), confrontation, clarification and interpretation.

To put these techniques into practice we have to use the musictherapeutical forms of intervention which are all kinds of improvisation.

7. Storz, D., 1999: 445

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The focus of interest is the free improvisation as a musical interaction between patient and therapist, in which early patterns of relationship are enacted again.

Experiencing these patterns is the presumption for the next steps which are: repeating, clarification, confrontation and finally interpretation.

Improvisations which are oriented on formal rules, themes or forms of communication support the structuring on the one hand and the clarification or confrontation on the other hand.

Of great importance is a conscious management of time. Referring to James Mann we divide the therapeutic process into 3 phases: In the fist phase the supporting improvisation is in the centre of attention and in this phase we aim for the development of a dynamic focus.

The second phase is dominated by the experience and the expression of the patient’s interpersonal world and by the enactments of his early patterns of relation.

In the phase of separation which is the last phase the central topics are to realise the patient’s wishes of the kind of interactions and to work on themes referring to the discharge and the farewell.

The essential point in this concept is the musictherapeutical work with a dynamic focus. This focus serves as our reference point during the whole therapeutic process.

The Dynamic Focus The dynamic focus has to be worked out to understand the patient with his failed patterns of relation and his ineffective attempts of conflict solving. And also as a decisive help for not losing the goal in the course of the common musictherapeutical improvisational work.

Based on the transference situation in the musical interaction the focus should refer to an interpersonal pattern of relationship which has been biographically important and still creates difficulties in the actual life.

Both the biography and the actual life situation is explored in interviews.

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The Dynamic Focus

But the situation of transference becomes perceptible and audible much quicker in the musical interaction than it does in therapeutic interviews.

So from the very beginning, the musical interaction has a specific function in providing useful hints about how a patient habitually represents interpersonal relationships. The common improvisation shows how the patient creates the relationship and it also shows what the basic expectations of the patient are.

When we formulate the focus the central impressions and the information we already have are being connected and interpreted. We have to name the patient’s strategies behind his current patterns of behaviour – for which he certainly had a good reason in the past but became destructive to a certain extent in the present.

The formulated focus should be about 2 to 3 sentences.

A CLINICAL EXAMPLE:: MS. D.

A 24 year old woman came to the department with the diagnosis: Borderline psychosis with heavy depression and eating disorder.

She talked about an emptiness, uncertainty, being without orientation and a bodily misperception of dissolving. She also mentioned difficulties with limits and boundaries and a tendency to follow other people and to have to do what others do.

She had a very negative self-perception which resulted in anxiety and which also could lead to the feeling of dissolving and massive self-devaluation.

Ms. D. grew up on a farm in a small village in Austria. Her father was very strict and did not talk much whereas her mother was overtaxed from work. Ms. D herself had a particular function for her mother, namely meaning not being alone. Her mother was overprotective and the patient was quite restricted in her activities. She talked about her role as an outsider and already in the kindergarden she had problems to get into contact with others. Even with her 5 older brothers it was not possible to establish a (closer) relationship because they spent their childhood at a boarding school.

At the age of 9 to 13 she had a ”forbidden sexual relationship” – that’s how she called it – with a guy two years older than she. It was not really possible for her to talk about this relationship. The only thing she told was that she ended this relationship because the guy talked in an insulting way about her privately and in the public over and over again. When she was 14 she went to high school which was a boarding school that meant she had to leave the parental home. Since that time she has

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felt without any orientation but nevertheless she could finish the school with a positive high school diploma.

Afterwards she went to Vienna, lived in a student house and started at university â&#x20AC;&#x201C; the nutritional science course. Very soon she fell into a miserable and stressed mood with anxiety, sleeplessness and the feeling of making everything wrong.

The following symptoms were eating difficulties, heavy affective outbursts, weeping spasms, crying fits and at least psychotic symptoms like ideas of reference and delusional ideas. So she stopped her studies and went back to her parents, but her state deteriorated more and more, hence her parents took her to the next hospital.

At the rehabilitation department her goals were to develop a better feeling of reality, to find more orientation, to work on her self-esteem and on her problem of identity and to improve her interpersonal abilities.

The team on the ward suggested that central topics for her were how to accept herself and how to accept the need to be understood and to be loved as well as the need to reconcile with the aggressive part of her personality.

In our first musictherapeutical session she was very shy and it was hard to get into contact with her. She talked very little and answered my questions only.

Again and again she tried to catch my eyes and it seemed as if she watched every single movement in my face. She appeared to be frightened but also sceptical and curious.

We talked about the character, sense and procedure of the music therapy, the sense and possibilities of a common music therapeutical work. Finally we had agreed on two sessions per week during her stay at the department.

The first sessions were to get familiar with the instruments and to explore them and to get an idea of the different possibilities of playing them. After this we could start with our musical interactions.

Right from the beginning she could use the free improvisation in an amazing way.

Not only could she find musical impressions for her inner life in a very differentiated way but also was she interested in my part and in our common musical interactions.

My feelings and reactions which came up more and more were:

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The Dynamic Focus

• The feeling of being controlled • The feeling of being tested, whether I am doing and understanding well enough • The feeling of controlling myself so that I do not fail to hear something and that I don’t say a wrong word or play ”wrong”

• The feeling of not being able to ”give” enough to her meaning that she never gets enough

Her general expectations referring to others and to my reactions:

• She was sure that others would reject her – me too. These fears were nourished

by her memories of heavy mocking and constantly teasing during her kindergarden and school time.

• She seemed to be afraid of being disappointed by me.

Her reaction in the musical interactions:

• She was looking for love and care • She perceived relation qualities very quickly • She was mostly dissatisfied with her reactions (because she could not answer good enough)

• When she ”failed” in her attempts answering my musical acting she derogated herself and withdrew from the relation.

• Therefore after lots of intensive and exciting improvisations she was in a sad and reproachful mood

These components made me to formulate the focus, which served as our common basic motif. It is important that the formulated focus addresses her personally and was: »In our improvisations it seems as if you try hard to show me what you need from me. And at the same time it seems as if you fear that I will not be able to perceive and to understand your needs. I also have the impression as if you are sure that I am not able to reply well enough. Your presumptions put you under the same strain as it was in your childhood. Your reaction is to withdraw from our relationship and to go back to your well know feelings of being left alone and of being full of selfdoubts as you did in former times.«

Initially Ms. D. was quite disturbed about this interpretation because she supposed criticism and rejection behind this idea. But when I emphasized the logic of her atti-

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tude and her behaviour and the way it was connected to her biography she could – after a while – agree with interest and relief to this interpretation.

This formulated focus was our guideline for the whole work.

We created quite diverse improvisations and she was able to express her mental state – her troubles and difficulties as well as her pleasant feelings.

Again and again we had to cope with the difficulties as formulated in the focus: her expectations and the withdrawing from the relationship in order to avoid disappointments. By the time she was able to recognize these processes more and more consciously. Whereas at the beginning she was very negative about herself and later on she could gradually reconcile with these parts of her personality and at the end of our work she could even be partly humorous about herself.

Summarizing the musictherapeutical work with a dynamic focus means that the whole musictherapeutical process is dominated by the components of the relationship in the musical interaction.

The musical interaction represents something like an ”acting-relation space” which allows us to try out different patterns of relation so that they can be experienced and become clear. This offers the possibility to constantly link everything that happens in the improvisation to the formulated focus.

For the patient the advantage of a dynamic focus is that the musictherapeutical work becomes clear and comprehensible. Thus it is more likely that the patient develops a growing interest in himself and that he sustains this interest in himself.

Time limitation does not necessarily mean not to work psychodynamically but to use an appropriate concept. In this case it is the Focal Music Therapy Concept (FMT) which can be helpful for both the patient and the music therapist.

References Storz, D. (1997). “Musiktherapie im Rahmen psychotherapeutischer Teamarbeit in einem psychiatrischen Krankenhaus.” In: Elena Fitzthum/Dorothea Oberegelsbacher/Dorothee Storz (Hrsg.), Wiener Beiträge zur Musiktherapie. Weltkongresse Wien Hamburg. Wien: Edition Praesens, 101–122.

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References

Storz, D. (2000).Musiktherapeutische Techniken. In: Gerhard Stumm/Alfred Pritz (Hrsg.), Wörterbuch der Psychotherapie. Wien, New York: Springer, 444–445.

Storz, D. (2003). Fokale Musiktherapie. Entwicklung eines Modells psychodynamisch musiktherapeutischer Kurztherapie. Wien: Edition Praesens.

Strupp, H. & Binder, J.L. (1993). Kurzpsychotherapie. Stuttgart: Klett-Cotta.

Walter, Bruno. (1947). Thema und Variationen. Frankfurt a. M.: S. Fischer Weghaupt, A. (1998). Psychoanalytische Kurztherapie: Ein Überblick. Psychotherapie Forum, Vol. 6 No. 4, 1998, 195 – 205.

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Music Therapy Today, Vol. VI, Issue 4, (November 2005) a publication from MusicTherapyWorld.net

CHAPTER 56

â&#x20AC;&#x17E;Low technologyâ&#x20AC;&#x153;; necessary aids in music therapy practice with children and adolescents suffering from

multiple serious impairments

Thoms, Karen

Proceedings of the 6th European Music Therapy Congress

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Editors note: Check for the html version with all video and audio files on MusicTherapyToday.com (November 2005)

Perhaps I should have been honest and should have chosen a different title for my presentation, something like

“Not the chimes again!” – Looking for alternatives to chimes in music therapy practice with patients suffering from multiple serious impairments This title is a first indication of why I began to look for ways to design and construct aids and devices for music therapy practice. Five years ago I would not have believed this could become a central issue in my work – but five years ago I did not know the place where I work today, the “Lebensarche Königsborn”, nor did I know the residents of this institution. The aids and devices I shall present here are a result of my work there, tested and tried out many times and changed and refined accordingly. The inhabitants of the Lebensarche gave and give clear and honest indications whether and in which context these aids are suitable or not.

This is why I shall begin with a short presentation of this institution and its inhabitants, and then go on to describe my work as a music therapist and the challenges I faced from the start. Then I shall present a number of aids and devices constructed for music making, and show videos from therapy sessions to illustrate ways to use such devices.

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1. Lebensarche Königsborn

1. Lebensarche Königsborn Lebensarche Königsborn is part of a larger institution called Lebenszentrum (or life centre) Königsborn – a centre for patients with neurological diseases or impairments. About five years ago this centre was reorganized, and the clinic for pediatric neurology with 50 beds was turned into a residential home. This type of care corresponds to the specific needs of pediatric and adolescent patients; their serious impairments in daily life require permanent support by therapists, teaching and nursing staff. For a variety of reasons, this care cannot be provided at home; therefore, children and adolescents between 0 and 24 years from Northrhine-Westfalia live in this centre for many years. Their serious multiple impairments are caused in most cases by traumatic brain injuries, inflammatory brain disease or neuromuscular disease.

After reconstruction, the Lebensarche now gives room to 6 groups with 8 inhabitants each , with family-type structures and supported by an interdisciplinary team of carers. 15 therapists provide their services according to the individual needs of the inhabitants. Children and adolescents at school age attend a special education school.

2. Music therapy at the Lebensarche I came to this institution five years ago and have been working as a full-time therapist for the last three years. I see all 50 inhabitants in music therapy in the form of alternating therapy blocks, mainly in single sessions. The objectives of my efforts are varied and comprise relaxation, perception or stimulation of contact and interaction. Although the children and adolescents have serious impairments of motoricity and also cognition, it has always been my intention to involve them in an active way. For example by reflecting and imitating their respiration and movements in music. In addition, I am always looking for ways to let them actively participate in music-making with instruments.

I have a wide range of instruments in my therapy room: drums, rattles, castanets, and triangles. Along the wall, there are a slit drum (Big Bom), cymbals, metalophone, pipedrum, sound bowl and chimes. As many inhabitants of the Lebensarche suffer from cerebral paresis, or marked spasticity and athetosis in movement patterns, it is difficult to involve them in active music-making. From the very beginning, only the chimes turned out to be suitable to make even smallest movements audible, and to integrate uncoordinated movements.

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Consequently we are challenged to improve the conditions in which patients with serious multiple impairments can find access to, and use appropriate instruments.

The traditional instruments in a therapy setting may in fact be played without previous experience. Nevertheless, there are some basic preconditions for music-making with instruments:

• First of all, we need movement – no sound, of instruments or otherwise, can be produced without movement, e.g. the movement of hands and arms, or the movement resulting in inhaling and exhaling.

• For the drums or castanets we need in addition a directed movement, a movement towards the instrument; this may of course be facilitated with a flexible position of the instruments but is required nevertheless.

• With the metallophone or cymbals, there is an additional requirement: a stick has to be gripped and held firmly in order to be taken to the instrument.

• Many times I saw a patient grip a stick and guide it towards the instrument, but

if the movement was very slow then there was no satisfactory sound. It is a deeply frustrating experience to see somebody sit in front of the cymbals, mak-

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3. Aids and constructions for music-making

ing a tremendous effort to take the stick to the instrument slowly and then to softly drop it to the cymbals without a sound â&#x20AC;Ś another precondition is therefore a minimum of speed in the movement.

â&#x20AC;˘ In the case of stringed instruments, e.g. the lyre, sound is produced by plucking the strings, which requires mobility in individual fingers.

We tend to underestimate these requirements because we do not have to think about them. But if you work in an institution such as the Lebensarche then you are confronted with such problems. The inhabitants challenge us to take a closer look at the things we normally do not think about, and at the basic requirements in particular.

3. Aids and constructions for music-making 3.1. TILTING TABLES WITH ADJUSTABLE HEIGHT

In music therapy with seriously impaired patients, the mere positioning of instruments is very important; instruments must be adjusted as exactly as possible to their needs. They require tables and fixtures that can be adjusted flexibly as to height and angles.

Wooden boards fastened to metalophone stands with screws have turned out to be useful. Such tables permit e.g. to set instruments up on end, or castanets may be fixed hanging downwards, so that they can be moved with feet. We shall see more of such table constructions later on.

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3.2. FUNCTIONAL GLOVE / SANDAL

As mentioned above it is difficult or even impossible for many inhabitants of the Lebensarche to get a firm grip on an object or to hold on to it. Some of them are able to grip a stick, but their play on an instrument is often interrupted by an uncontrolled opening of the hand: the stick falls down, and the joint play stops. This is why we designed a glove with Velcro fastening; another Velcro fastener at the handle of the stick ensures that the stick is held even if the hand opens. I think it is important that the natural grip of the hand is involved and that the Velcro fastener is only a safeguard.

Clients have to be observed closely in music therapy; when they let go of the stick, this may also indicate that they just wish to stop playing. We must be aware of this possibility!

Normally we use hands and arms to play drums, cymbals or glockenspiel; for some inhabitants of the Lebensarche it is easier to use their feet and legs. Therefore we had to design devices to fasten sticks to the feet, and this is the result: a sandal with Velcro fastening adjustable to the size of the foot, with quivers or loops at the sides

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to hold sticks or instruments. This sandal for sticks permits music-making with feet or legs.

3.3.HEAD FIXTURE WITH STICK

In several cases I also use a kind of fixture to the head – a device that makes use of head movements. This is not my own invention – it was designed for work at the computer keyboard, and I used the idea for music therapy. For Nermin e.g. I fastened the plectrum of a guitar to a short wooden stick and screwed this into the head fixture. Therefore she is able to play the lyre with a head movement. ® 4. SCHNUKOS®

The next device I want to show you are Schnukos® – this is an abbreviation of the German word “Schnurkonstruktion” or cord construction. The point of these cord constructions is that the movement is transferred to the instrument via cords. Many patients are able to move their arms, legs or head, but a controlled movement towards the instrument is almost impossible because of athetotic motor disorders, i.e. uncoordinated and overshooting movements. The Schnukos® allow to transfer motor impulses of all types to the instruments in such a way that movements become audible and instrumental play becomes possible. The simultaneous coupling with a sound-producing instrument may promote and support a patient’s perception of his own activity and his sense of self. The Schnukos® allow to hear, experience, perceive and perhaps to enjoy movement.

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4.1. SCHNUKU (SCHNUR-KUGEL-KONSTRUKTION OR CORDSPHERE CONSTRUCTION)

My very first Schnuku consisted in nothing but a long cord, a wooden sphere and a stand; one end of the cord is fastened to the stand. Drum, cymbals or glockenspiel are positioned accordingly.

4.2. KUPIPE (KUGEL-PIPEDRUM-KONSTRUKTION OR SPHERE– PIPEDRUM-CONSTRUCTION)

Subsequently I designed the Kupipe – a construction where a wooden sphere runs along the edge of the up-ended pipedrum. The tilted table permits a vertical position of the instrument. An important discovery for me is a deflector role: it serves to take up and integrate the movements even better.

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4.3. TRIANGLE TREE

The triangle tree is based on a similar idea. Several triangles are hung into a wooden frame. A metal sphere or iron nuts are directed to the triangle via a deflector role and produce sounds.

4.4. SEESAW-TABLE

The seesaw table is another alternative. A wooden box is hung up in a freely movable position and may be tilted forward with a cord; a weight at the back wall causes it to tilt back. In this wooden box we may fasten e.g. an oceandrum. But more frequently I use a wooden sphere on a track or rail that causes claves to sound at both ends.

An important characteristic of these Schnukos ® is that not only one direction of movement produces a sound of the instrument – as is normal with drums, metallophone or other percussion instruments – but that the movement in the opposite direction becomes audible as well: movement up and down, back and forth.

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4.5. LEVER STICK

In addition to the normal Schnukos®, other cord constructions have been designed which make use of the lever. As mentioned above, some of my clients are so slow in their movements that they produce almost no sound at all on an instrument. This is why I designed the lever stick. The principle is very simple: a hole is drilled into a stick and the stick is hung up so as to move freely. Even a slight pull at the short end of the stick causes the tip to move a far longer distance, and more rapidly, in dependence on the ratio between short and long part of the stick.

4.6. KUPIPE WITH LEVER STICK

The idea of the lever may be combined with other cord constructions as well. The last Schnuko® I want to present to you is a pipedrum with a lever stick. The principle is the same as before; but this time I fastened a cord with a wooden sphere at the end of the stick. In the example presented here it is enough to pull 4 cm in order to guide the sphere over all pipes of the pipedrum.

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5. Types of fixtures or fastenings

5. Types of fixtures or fastenings What about the fixtures or fastenings to play the schnukos?

• The therapeutic glove, the stick sandal or the head fixture may be employed to use movements of arm, leg or head in music-making with Schnukos.

• In addition, we may use simple wooden or plastic handles or rings.

• This hand grip was made specifically for the Schnukos. It uses the normal gripping movement; Velcro fasteners over the back of the hand and around the wrist make continuous play possible.

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I discovered a very cheap alternative to the stick sandal in a toy shop: Bobbycar shoe protectors! They have a rubber coating that is glued to the fronts; I replaced it with a Velcro fastener, glued another Velcro fastener to a wooden cube and added a ring screw, and had produced a wonderful device for music-making! Two of these for just 8 Euro!

Moreover Schnukos ® have some other advantages:

1.

2.

3.

Hygiene is easier to ensure with patients who suffer from infectious diseases.

Wooden handles are inexpensive and may be provided for each patient.

For patients with impaired vision, the tactile impulse may support and maintain contact with the instrument.

Instruments may be positioned in more variations and need not be placed directly near or in front of the face or head.

6. Plectrum stick Stringed instruments may be easily used with the help of plectrum sticks. A simple guitar plectrum is fastened to a wooden stick with a saw cut.

Depending on each patient’s condition and abilities, it may be fastened to a T-stick, or to a longer wooden stick that may be fastened in the foot fixture.

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7. Conclusion

7. Conclusion In conclusion I would like to come back to the preconditions for making music on a variety of instruments, and to describe how it became possible to ensure a satisfactory and joyful play on instruments even without these preconditions.

• One condition is the ability to close a fist in order to get and keep a firm grip on

a stick. The therapeutic glove, the stick sandal or the head fixture make it possible to play an instrument with hands, feet or head. Velcro fasteners permit something like continuous play.

• Another precondition is the directed movement towards the instrument. Cord-

constructions help to translate all kinds of movement patterns into music-making on instruments. The cord serves as a “funnel” between player and instrument.

• Even the requirement of a minimum speed may be evaded: • The lever stick, either alone or in combination with other devices, may considerably accelerate or enhance movements.

• A plectrum stick may facilitate music-making on the lyre or other stringed

instruments even for patients who are unable to make plucking finger movements.

The search for alternatives produced first results; we designed aids that helped to involve almost any type of movement into the production of sound – and this is what we see in the music with chimes, irrespective of the body part that moves, and irrespective of the speed or direction of the movement.

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In my therapy sessions, I am always impressed by the concentration, the persistence and also the delight and pride with which children and adolescents react to the new possibilities to make music; this shows me that we have chosen the right direction, and I am looking forward to seeing where this path will lead us.

I want to conclude my remarks with a quotation by G. Dörr that has influenced my work again and again; I hope it encourages all of us to go on looking for new ways and developing new ideas: “Serious physical handicap seems to be an obstacle; in reality it challenges our imagination. If th erns the way we treat each other then this is integration, and integration in this sense will eventu become a path on which both involved parties move along and take steps towards each other. No this is not possible.”

(G. Dörr) a a. DÖRR: Vorwort. In: Fröhlich: Kommunikation und Sprache körperbehinderter Kinder. (1989, S.8)

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Music Therapy Today, Vol. VI, Issue 4, (November 2005) a publication from MusicTherapyWorld.net

CHAPTER 57

Home alone: The use of familiar precomposed songs in individual homes of the elderly

Thomas, Amy BMusEd, GradDipMusTh, RMT Calvary Health Care Bethlehem Melbourne, Australia

Introduction What I wish to present to you today is how music therapy in the individual homes of the elderly can assist in the re-engagement of positive feelings, and thus reengaging them with coping skills. Music, and in particular familiar pre-composed songs, evokes strong and positive memories. This reminds them of positive emotion and allows them to re-engage with a previous time when they could cope. This allied health profession is viewed by medical professionals in the community as offering a creative medium for expression which fills a gap in health care in Australia.

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An increasing number of elderly people with high-level needs are remaining in their homes for a longer period of time and for a variety of reasons. This trend in Australian health care has caused a shift in service provision and requires a range of support services. With longer waiting lists for nursing homes, government and private organisations have implemented and increased home services in Australia.

These services include home help in cleaning, food preparation and shopping. The increased number of services in the home often delays the immediate need and decision to move to a nursing home or hostel, until it is absolutely necessary. In the mean time the many issues of ageing accumulate. Despite the services provided in the home, these people often face similar challenges of ageing to those of nursing home residents including grief, loss, depression, increasing dementia, isolation and coping difficulties.

Music therapy, and in particular the use of familiar pre-composed songs to facilitate reminiscence, has been widely used in the care for the elderly. It has traditionally addressed physical, emotional and social needs with this population in nursing homes. Through case vignettes, this paper will demonstrate the effective use of familiar pre-composed songs in the homes to remind elderly people of re-engage with feelings of happiness and thus assist them to cope in their homes independently for as long as possible.

Familiar Pre-composed songs with the elderly We understand music therapy to have many positive effects for the elderly population. Sato Ashida reported of music therapy research in this population to increase motivation, increase self-expression and communication, evoke memories, provide a sense of accomplishment and address short term memory loss. A well used music therapy technique known to us with this population is the effective implementation of familiar pre-composed songs. In Australia, this is the most common experience of music is through song, and this is subsequently a very age appropriate format with the elderly population. They are often songs people grew up with, sang around the piano and danced to. The use of this type of music provides “…structured reality, order and predictability…” whilst facilitating reminiscence and discussion associated with emotions such as loss, grief and isolation. (Clair, 1996) They hold associations of people places and events. Suzanne Hanser (1990) discusses how these associations with familiar music often evoke pleasant memories, providing a stimulus in music therapy sessions for positive life review. This music therapy technique can be effectively used as the ageing process progresses physically or cognitively. With increased dementia the retrieval of verbal language becomes

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Music therapy in the home

increasingly difficult, and it is the use of familiar music associated with positive experiences and memories that is most likely to evoke a response (Clair, 1996).

The implementation of familiar pre-composed songs in a music therapy session with the elderly often has a focus on reminiscence and life review. However it also provides a perceived â&#x20AC;&#x153;safeâ&#x20AC;? environment for people to share their memories (Ashida, 2000) and meaningful experiences. The music can instil a sense of reassurance and companionship and this use of music helps to evoke meaningful interactions between the therapist and participants.

Music therapy in the home According to the Australian Burea of Statistics in 2001, between 1981 and 2001, the population of people over the age of 65 who lived in some form of aged accommodation with supports, increased by 500%. It is anticipated that our ageing population will only continue to increase. The consequences of ageing include dementia, depression, isolation and disempowerment. These can cause impairment in activities of daily living (Monini et al., 1998), psychological distress in the elderly and their carers (Brodaty &Luscombe, 1998), and higher rates of institutionalisation (Folstein, 1994). It may also cause peopleâ&#x20AC;&#x2122;s coping skills to be disabled. With the ageing population of Australia increasing, and nursing home beds becoming harder to obtain, general home based programs and supports to care for the elderly are beginning to become an important part of our community.

Music therapy in the home is relatively new for our profession. Home based palliative care services are well established in Australia and continuing to increase in size and number. Whilst traditionally addressing issues of ageing in nursing homes and hostels, the implementation of music therapy in the homes of the elderly has many benefits. Music therapy sessions with familiar pre-composed songs emphasize meaningful experiences, allowing participants to focus and re-engage with positive feelings of happiness and uplifted spirits. Music therapy becomes a point in their weekly life, enabling them to feel empowered as they look forward to their next session. This positive experience created through regular music therapy sessions in the home with familiar music can assist the elderly to remember a time in their life when they were able to cope. It therefore impacts on the delay for the need of admission to a nursing home.

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Calvary Health Care Bethlehem In 1999, Calvary Health Care Bethlehem and the Royal District Nursing Service were successful in obtaining government funding to implement a home-based music therapy program. This program is provided for the frail aged with psychosocial needs who live in their own home. These two health facilities have worked closely together to provide better care for the elderly in the community.

Calvary Health Care Bethlehem is a public hospital in Melbourne, Australia, owned and operated by the Sisters of the Little Company of Mary. The hospital cares for people suffering with progressive neurological disorders, or people diagnosed with cancer or other illnesses who are in the last months of their lives. The music therapy department of Calvary Health Care Bethlehem largest of its kind in Australia, with 7 music therapists providing services to in-patient, home-based and outreach services including the program provided to the Royal District Nursing Service.

Royal District Nursing Service The Royal District Nursing Service aims to provide their clients with effective and efficient quality home health care programs 24 hours a day. The music therapy program is part of the allied health team who works in conjunction with nursing to provide a holistic approach of care within the home.

Home-based music therapy program The Royal District Nursing Service has 20 centres across the Melbourne metropolitan area, and the music therapy program is run 2 days a week over 2 centres. Clients of the Royal District Nursing Service are referred to music therapy for a variety of reasons, predominantly to assist in their general care management and well-being.

This program provides music as an age-appropriate format to address issues which are not able to be addressed by nursing staff in the time allocated or with the skills required. The reasons for referral to the music therapy program include social isolation, dementia, anxiety, pain management, and emotional or spiritual support. All of these reasons for referral impact on an individualâ&#x20AC;&#x2122;s independent living and coping skills.

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The following case vignettes give examples of the effective implementation of familiar pre-composed songs in music therapy sessions. All names have been changed for issues of confidentiality and permission granted for use of material.

CASE VIGNETTE 1

Jim, is an 87 year old man, who presented with short term memory loss, depression and insomnia. He lived alone in a one bedroom unit, and was being visited by the district nurse daily for management of medications.

It was observed by the district nurse that Jim’s general health and independence was deteriorating. Jim would often stay in bed all day without getting dressed, his home was becoming increasingly unkempt, and he reported increasing insomnia with intrusive nightmares, centred around the death of his first wife in 1955. He was referred to music therapy by his primary nurse to address increased confusion, depression, short term memory loss and grief issues.

On the initial music therapy visit, Jim presented with a very low spirits. He was very open about the difficulties he was experiencing and also expressed feelings of guilt and that he could not see the point in life any more. Due to the complexity of his feelings of guilt I will not expand on this reasons relating to this. He was willing to accept music therapy, however made it clear to the therapist that he did not feel it would benefit him. Over a period of months the music therapist played live familiar music at his bedside during sessions to stimulate discussion and reminiscence, whilst addressing the death of his first wife. The music therapist played familiar pre-composed songs such as “Heart of My Heart” and “The Street where you Live” from ‘My Fair lady’. The playing of this familiar music and manipulation of tempo by the therapist stimulated increased conversation by Jim. The song “Wouldn’t it be Loverly” from ‘My Fair Lady’ had particular meaning to him.

All I want is a room somewhere Far away from the cold night air With one enormous chair – oh wouldn’t it be loverly

Lots of chocolate for me to eat Lots of coal, makin’ lots of heat Warm face, warm hands warm feet – oh wouldn’t it be loverly

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Oh, so loverly sittin’ abso-bloomin’-lutely still I would never budge till spring, crept over the window sill

Someone’s head restin’ on my knee.

Warm and tender as he can be Who takes good care of me Oh, wouldn’t it be loverly Loverly, Loverly Loverly, Loverly

The music therapist used the words of this song to stimulate discussion about what he had hoped for his marriage, before his wife died. They were pleasant memories, and pleasant dreams, and enabled Jim to comfortably express emotion such as laughter and tears.

The majority of sessions centred around the death of his first wife and associated guilt, and was supported by the music therapist with appropriate familiar pre-composed songs such as this one. Verbal prompting was occasionally used by the music therapist due to Jim’s memory loss. With the music therapist allowing the song stimulated discussion to flow freely Jim, was also able to relive pleasant memories and enjoyable activities such as music and gardening. Gradually Jim was able to recall more songs during music therapy sessions, indicating uplifted spirits and creation of increased stability in his life. He began to request music therapy sessions in his living room, where the photos of his wife and family were kept, and often referred to them following songs such as “One Enchanted Evening”, recalling his days as an usher at a movie theatre and his days of dancing.

Jim now receives music therapy fortnightly. He often greets the music therapist in his garden, where he works hard in on a daily basis. He receives daily nursing visits for medication, and home help once a week. He is becoming frailer and his dementia is becoming more evident, however he lives relatively independently with support and does not wish to leave his home and his garden. His nightmares now occur only occasionally.

It was believed by the primary nurse, that music therapy was a strong contributor to Jim’s uplifted spirits, motivation and maintenance of independence as it was the only change to his general care. Jim continues to address issues of grief and guilt

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during music therapy sessions. The music therapist plays familiar pre-composed songs which are known to elicit a verbal or emotional response by Jim, remind him of his wife, and create an appropriate environment for him to express his emotions comfortably. This implementation of familiar pre-composed music in the home, is a positive experience for Jim. It has enabled him to establish better coping mechanisms through the stability and predictability the songs create. Jim speaks very highly of music therapy to his primary nurse and the music therapist, and looks forward to his fortnightly sessions. His primary nurse no longer raises the issue of placement into a nursing home.

While Jim’s case was an example of the implementation of familiar pre-composed songs for an elderly person who lives alone, the following case vignette illustrates the same technique with a carer to assist in coping skills and effective care management in the home.

CASE VIGNETTE 2

Mathew was a 75 year old man presenting with multi-infarct dementia. He lived at home with his wife Mary in their second marriage. Both of them had experienced multiple challenges in their lives, including the loss of children and alcoholism.

Before the deterioration of his condition, they made the decision for Mathew to be cared for at home. This was something Mary felt very strongly about, and she was determined to care for her husband in the best way possible. As a consequence of her determination regarding this, her anxiety levels and criticism towards nursing staff increased, and Mathew’s confusion escalated during these tense periods. Nursing staff found this difficult to manage and therefore had increased difficulty in providing adequate care for him to remain at home. The nursing staff’s home assessment revealed both Mathew and Mary had extremely high care needs including hygiene and management and appropriate care techniques. They also had psychosocial needs such as unresolved grief, expression of emotion and coping difficulties. These needs were not able to be addressed by nursing staff, predominantly as their visiting time was limited and there were many issues to address.

Nursing staff felt music therapy may assist Mathew and Mary address emotions they were currently experiencing and develop coping strategies in Mathew’s management of care. Mathew was referred to music therapy for memory loss, disorientation and confusion, agitation, social isolation and difficulty expressing emotion.

Nursing staff intended to support Mary in caring for Mathew at home and resist the need for admission to a nursing home as per her wishes.

During initial visits, Mathew was usually in his wheelchair and was able to respond to verbal and musical prompts. This communication included the music therapist singing his favourite songs, such as “Amazing Grace” and “Look for the Silver Lin-

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ing”, with Mathew maintaining eye contact and singing. Through songs familiar to Mathew, the music therapist encouraged him to sing and the sessions subsequently offered a significant increase in cognitive stimulation. This stimulation was needed as he was dependent on Mary for his full care, and their relationship had therefore changed dramatically. In addition, Mary’s anxiety was often noted, exacerbating Mathew’s confusion. These sessions became important to reduce tension and anxiety whilst creating a focal point aside from Mathew’s care that they both enjoyed and responded to positively. Mary was educated by the music therapist in the appropriate use of recorded familiar music between music therapy visits. This use of music during the quiet times of the day, and when Mary was feeling particularly stressed, was important in Mathew’s holistic care.

Over the period of nearly 3 years that Mathew received music therapy, his condition deteriorated and he became largely confined to his bed. Periods of extreme confusion and anxiety had increased with little verbal communication. Music therapy sessions became increasingly important for Mathew and Mary by creating an intimate environment and as a time to share their relationship as husband and wife, rather than carer and patient. During these sessions Mary would request songs they enjoyed together and whilst they were played by the music therapist, she was able to communicate with Mathew and reminisce. There were a number of songs that were regularly requested. “The Way we Were”, “Danny Boy” and many of the songs of Dean Martin were requested. “That Lovely Weekend” was one of the songs regularly requested.

I haven’t said thanks for that lovely weekend, Those two days of heaven you helped me to spend The thrill of the kiss when you stepped off the train The smile in your eyes like the sun after rain

To mark the occasion we went out to dine, Remember the laughter the music the wine That drive in the taxi when midnight had flown Then breakfast next morning just we two alone

You had to go, the time was so short, we both had so much to say Your kit to be packed, the train to be caught

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Conclusion

Sorry I cried but I just felt that was

And now you have gone dear this letter I pen My heart travels with you till we meet again Keep smiling my darling and someday we’ll spend A lifetime as sweet as that lovely weekend

This song reminded Mary of when Mathew sang to her on their honeymoon. The music therapist often manipulated this song in tempo to create an appropriate environment which supported their emotions and allowed them space for expression.

Listening to this song with Mathew, allowed Mary to express her emotions appropriately in their own home.

Familiar pre-composed songs were important in this phase of music therapy. With the music therapist playing familiar songs an environment they perceived as emotionally stable was created and thus supported their issues of grief and loss. The music therapy sessions enhanced open discussion regarding the ageing process, reengaging them in positive emotions of shared experiences such as the times they enjoyed dancing. This re-engagement and emotional support through music therapy sessions with familiar pre-composed songs filled the gap in the health care provided and assisted in re-establishing coping mechanisms. Mary’s improved coping skills prevented the need for Mathew to be admitted to a nursing home.

Following Mathew’s death, the music therapist compiled a tape of recorded music for Mary. It included the music therapist singing some of their favourite songs. This was important to Mary as she often commented that the experience was always different when the music therapist sang the songs rather than listening to them on a tape. This familiar music on tape, assisted Mary in the grieving process by allowing her to remember the enjoyable experience that music therapy provided in Mathew’s final years.

Conclusion These case vignettes demonstrate the effective use of familiar pre-composed music in homes of the elderly to address issues of ageing and assist in maintaining independence and coping skills. As the population in Australia continues to age, nursing

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home beds are becoming fewer, and more people will remain in their homes for as long as possible. The accumulated consequences of ageing need to be supported and addressed for these people in their own home with a shift in service provision.

The strong positive experience of music therapy and the memories it evokes, allows re-engagement with happy emotion and a time when people were able to cope. The implementation of this music therapy program, has made this unique therapeutic medium more accessible to our elderly population living in the community.

References Ashida, S. (2000). The effect of reminiscence music therapy sessions on changes in depressive symptoms in elderly persons with dementia. Journal of Music Therapy, 37(3), 170-182 Brodaty, H. & Luscombe, G. (1998). Psychological morbidity in caregivers is associated with depression in patients with dementia. Alzeimer’s disease and Associated Disorders, 12(2), 62-70.

Clair, A.A. (1996). Therapeutic Uses of Music for older Adults. Baltimore, MD: Health Professions Press.

Folstein, M. (1994). The noncognitive symptoms of Alzeimer’s disease. Journal of the Neurological Sciences, 127(1), 1-124.

Hanser, S.B. (1990). A music therapy strategy for depressed older adults in the community. Journal of Applied Gereontology, 9(3), 283-298.

Monini, P., Tognetti, A., Sergio, G., & Bartorelli, L. (1998). Depressive disorder in Alzeimer patients: Different aspects in the early and late stages. Archives of Gereontolgy and Geriatrics 1006, 343-346.

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Music Therapy Today, Vol. VI, Issue 4, (November 2005) a publication from MusicTherapyWorld.net

CHAPTER 58

From child care institution to foster family- supporting interaction by means of music therapy

Tuomi, Kirsi Kirsi Tuomi is a music therapist working at Nikinharju foster care institution in Finland. She also works as a private music therapist with children and adolescents.

She has just finished her Master studies in music therapy at the University of Jyväskylä. She is the vice-president of the board of the Finnish Society for Music Therapy.

1. Introduction In this presentation I will introduce you a model of music therapy developed in Nikinharju kuntayhtymä, where I work. The purpose of this model is to help the child to adapt to a foster family after living in a child care institution. Participants were foster and adopt families. The model was developed because of practical viewpoints. In the child care institution the nurses felt their work didn´t have continuity after child had moved to a new family. On the other hand the new families often felt they needed support when the placing process was topical. Music therapy seemed to be a good tool at this point. I knew these children from music therapy groups held in the child care institution, sometimes even from a single music therapy process. I was also interested in this kind of work with families.

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In addition to the theories of Donald Winnicot and Daniel Stern the paradigm of the model is the attachment theory. British psychiatrist John Bowlby thought that the attachment theory he had created was some variation of psychoanalysis. Attachment theory is partly based on the observations made of how a mother takes care of the security of her young ones in nature. Animal babies become attached to their mother and try to be close to her. (Kalland et al. 1999.) A human child has the same kind of behavioral system the purpose of which is to keep the distance to the care giver as short as possible. (Sinkkonen et al. 2001; Goldberg et al. 2000/1995; Goldberg 2000; Bowlby 1997.)

The nature of child´s attachment varies and a child can become attached either securely or insecurely (Kalland et al. 1999). A securely attached child has not needed to be afraid much and he/she can flexibly change his/her behavior along the circumstances. The more difficult and traumatic environment has been and the more insecure the attachment has been the harder a child holds on the working models he/she has adopted. From the viewpoint of treatment this is a challenge.

Sometimes it can take years before a child has the courage to try some other way of beeing in interaction. (Sinkkonen 2001.)

Either ways the attachment is very often the big issue when it comes to foster care.

These children may have been maltreated both emotionally and physically. They have experienced losts in many levels and have poor trust in people. The attachment models they have adopted are often, almost always, very insecure and one purpose of the therapy with these children is to create a relationship where the attachment can be secure. This is also the main target of the model I am today presenting to you.

2. Introcution of the model Experiments of this music therapy model were started in year 2002 and till spring 2003 there had been seven processes altogether. Four of these children moved to a foster family, one to a so called professional foster home and two were adopted. At the time of moving to the new family these children were of the age of one month to eight years. The meetings were arranged with large variety depending on the needs, motivation and possibilities of these families. There were two to thirteen meetings which mainly included meetings with the child and his/her primary caregiver, but also meetings with the whole family and/or part of the family were arranged.

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2. Introcution of the model

The target of this model is to support both the child and the family at the point of re-placing. On the other hand the purpose is to transfer the knowledge from the institution to the new parents. Music therapy can provide actual implements. With the help of these tools the family can deal with difficult issues such as being rejected, different feelings and changed roles. The interaction between the family members is supported by functional means with the help of music and other arts.

The meetings have included singing, playing with instruments and toys, music listening, working with pictures, drama, moving and dancing. The discussions have also been meaningful though then it has been important to pay attention to the age of different family members.

Some kind of path has been developed of this model. As I told you, I am familiar with these children already from the institution. I have been working with all children under school age at least in a group therapy but I have also met some children in a single music therapy. The aim of social care is to find a family for these children, either a foster or adopt family and children are placed in the institution for that time. Sometimes this period can take few months, sometimes even years. My job is mainly to assess and support these kids who have been through a lot.

When the family is found there will be general discussions about the possibility to have music therapy at the stage when the child and family is getting to know each other and after the actual moving has taken place. If the family is interested there will be a meeting in which the child, the family and the music therapist are taking part. It is to be hoped that the nurse and social worker from the foster care institution could also take part in this meeting. The working process and its goals will be discussed likewise the length of the process. Also an agreement is made. Luckily this plan can be reviewed during the process, in other words, if needed there can be less or more meetings than planned or the meetings can be aimed more, for example, at the whole family. The video filming is used as a tool and the tapes will be given to the family after the process is over. In addition, the family will get the lyrics of used songs. After the process is ended the therapist will make a written conclusion which the family is allowed to comment. With the permission of the family this conclusion will be given to the paying part. Also some kind of reflection of the process is wished from the family so that this music therapy model can be developed further.

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3. The case of Thomas 3.1 BACKGROUND

Thomas was born in December 2001 and he was the fourth child of his mother.

During the pregnancy the mother had used many different kind of narcotics. However, there was nothing abnormal in the delivery and the boy was of normal size.

During the delivery the mother was influenced by drugs, amphetamine, and left the hospital three days after the delivery. Thomas remained at the hospital because of his need to have special attention. Despite exhortations of the hospital the mother didn´t visit the hospital and Thomas after leaving. The father of Thomas had also an addiction to drugs. With the help of urgent custody, the nursery of Thomas was protected and social care got some extra time to find out what was going on.

Thomas had no clear withdrawal symptoms and so he moved to a child care institution at the age of two weeks. His siblings were also living at this institution. At the age of two months Thomas, however, was moved to Northern part of Finland were his parents had rehabilitation. Thomas got very sick and had meningitis. (meninggaitis) He was near to death, his skin was gangrened, it abcessed, was teared and went black and blue. Thomas had to stay in the hospital almost two months after which he returned to the child care institution. At that time the motor development had been left behind and Thomas was described as a restless little boy.

From the viewpoint of attachment theory the first six months of Thomas had been nothing but secure. There had been no primary caregiver to whom Thomas could have been attached and the basic security must have been shaken. This was realized in the child care institution and single music therapy was started.

3.2 MUSIC THERAPY

The music therapy process of Thomas had four different stages:

• • • •

Single music therapy, from the age of 6 months to 12 months (17 sessions) Couple music therapy with Thomas and his nurse (4 sessions) Couple music therapy with Thomas and foster mother (10 sessions) Music therapy with the whole foster family (3 times)

I have evaluated some parts of music therapy process by the means of CARE-Index created by Patricia Crittenden. CARE-Index is the simplest and most versatile of the attachment measures. It assesses mother-infant interaction from birth to about

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two years of age. It is based on a 3-5 minutes long videotaped material. The items of interaction that are observed in CARE-index are

• • • • •

The facial expression (responsive, incongruos, hostile or angry, impassive), Vocal expression (warm, strained, angry, flat), Position and body contact (compfortable and accessible, intrusive, awkward), Expression of affection (affectionate, covertly angry, overtly hostile, uncaring), Turn-taking (within bouts of play) (positively contingent, negativly/punitivly contigent, non-contingently uninvolved),

• Control (between bouts of play) (joint, adult, infant) and • The choice of activity (developmentaly appropriate, too demanding, understimulating).

These items work as a basis of video analysis I have made. In CARE-Index both mother and the child are observed. Because of the nature of therapy I must have, however, applied this assessment method. I have only used the items I presented to you and haven´t used the scoring system. The setting is also a bit different compaired to CARE-Index among other things because my job is to evaluate the whole process not only parts of it. When it comes to single music therapy I also realize that my main target is to assess the child not my own reactions. Though CAREIndex provides a good tool to reflection of your own work too. Today I am, however, concentrating on Thomas and his foster mother.

3.2.1 Single music therapy.

After Thomas had returned to the child care institution the single music therapy sessions were started once a week, 30-45 minutes at the time. At first the sessions were held in the ward were Thomas lived in, but were later on held in the therapy room which is located in the building next to the institution.

My first observations were that Thomas didn´t make any eye contact although he looked at my face a little. He wasn’t shy of me at all. On the contrary Thomas was laughing a lot, but my impression was that laughing wasn´t connected to interaction. During our first meeting Thomas didn´t turn around when lying on the floor, he couldn`t sit and seemed to be less muscular than the other children at his age on average. When I was making funny noises and showed my tongue to Thomas he paid attention only for short periods. He didn´t try to touch my face at all.

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The next video clip I am going to show you is from our eleventh session. At the time of this meeting Thomas was 9 and a half months old. The first clip is about ten minutes after the beginning of our session. In the sample I am singing a song which is about the different part of our faces.

VIDEOSAMPLE 1

The facial expressions or Thomas were irritated and the boy didn’t seem to be comfortable at all. He was making noises and was trying to say something – his babble had a meaning and direction. The position of Thomas was restless and he was more directed away from me. Thomas expressed his feelings and revealed that he felt uncomfortable. Turn-taking didn´t occur and I had the control of the activity likewise the choice of activity.

There are two important questions raised about this sample. Why was Thomas so restless and why did I keep on going? First of all, it is possible that Thomas could have just wanted to do something else. Maybe he was bored or, as he in fact did, saw something more interesting that he wanted (he actually saw an egg shaped maracass beside us). What would I have done in a normal interactional situation? I would have of course stopped and tried something else. But this situation was a therapy session the targets of which are different. I knew Thomas had difficulties to let me touch his face and also concentrate on my face. So at this point I made a decision to continue the interactional situation as far as I could. These types of situations are one of the reasons why CARE-Index cannot be used as such to assess therapy.

The next sample is from the same session about ten minutes later.

VIDEOSAMPLE 2

In this second sample the facial expressions of Thomas were very concentrated. His position was calm and he took physical body contact. In the hiding-game we shared the joy and played together. I had the control and the choice of activity though I

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was trying to take into consideration the acts of Thomas and get ideas from his behavior.

Significant in these two samples from the therapists´ point of view is the differences we can notice. Thomas almost seems to be like a different child when we compare the interactional skills of him in these two clips. It looks like Thomas got used to me during the meeting, maybe even started to remember our way of being together. From this viewpoint the therapy can be considered an effective way to influence the interactional skills. The progress can clearly be seen already during one session. The question is though whether these interactional skills transfer into other relationships.

The ending of the single music therapy was a decision of many weeks of conclusions. I had serious difficulties at the end of process to always try to turn the face of Thomas towards me. The way I see the purpose of the therapy is that I can try to make substitutive attachment experiences, but the purpose is not actually to make the child attach to me. After all, I wasn´t going to be his primary caregiver! The problem is how a child of this age can make the difference of these things. I had serious thoughts about the ethics of the single therapy. The final decision of finishing the process came to me when Thomas started to cry after the nurse had left him in the therapy room at the beginning of our sixteenth meeting. Though this cry of separation went over fast, maybe even too fast, it was a clear sign to me of the changed needs of Thomas. After discussions with the nurses of Thomas´ ward we decided to experiment a therapy with the nurse and Thomas together.

3.2.2 Couple music therapy with Thomas and his nurse.

The nature of foster care is that the events are difficult to predict. We didn´t know the schedule of Thomas´ staying at the institution or the moving to a foster family when we started the couple music therapy with Thomas and his nurse. Therefore we had time to have only three meetings just between the nurse and Thomas. In two of these meetings the nurse was so-called Thomas´ personal nurse. After the foster family was found there was one meeting in which the foster mother took part into and observed the music therapy session of Thomas and his nurse. If we could have predicted the fast finding of foster family this couple music therapy had not probably taken place at all and the single music therapy had continued as a couple music therapy with the new primary caregiver, foster mother and Thomas.

From Thomas´ viewpoint these couple therapy meetings were not much of a use.

The few meetings we had were however very useful if we observe my own learning. Already on our first meeting I realized that this kind of therapy is meaningful

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because of the transferability. Once a week –meetings with the therapist don´t remain in the mind of the child but if the same songs are played also in the ward in basic nursery situations achievements can be totally different. From the viewpoint of the attachment theory the presence of one same nurse would be ideal, and that would preferably be the so-called personal nurse. Music could work like a tool between the interaction of the child and the nurse and therapy meeting could be a moment of gold when the nurse could concentrate just on this child with his/her needs. And as you all can imagine those kinds of situations are rather rare within a common day in a child care institution.

3.2.3 Couple therapy with Thomas and foster mother.

A foster family was found for Thomas when the boy was fourteen months old. The family consisted of mother, father and three children – a ten-year-old boy, an eightyear-old boy and a five-year-old girl. All three children were foster children but they had moved into the family already in their very early childhood before they were six months old. The father worked outside the home and mother had stayed at home taking care of the children.

Like I already told you, the foster mother, who I here will call Jane, participated in music therapy as soon as the information of foster placement had been confirmed.

Jane became familiar with the couple music therapy of Thomas and his nurse mainly by watching and listening. In addition, Jane and I had a session were we together watched over the videotapes I had recorded from music therapy sessions.

At our preliminary meeting we made a deal about ten music therapy sessions between Thomas and Jane and besides of that, three music therapy meetings with the whole family. We had an agreement that we would meet once a week and the family sessions would take place at the beginning, in the middle and at the end of the process. One session would last forty-five minutes.

Discussions with the foster mother became an important part of these meetings.

The discussions took place unconstrained between other activities. Jane brought up the reactions of other children but mainly the discussions handled directly Thomas and the matters of his development. The lack of being afraid of strangers was annoying Jane in particular. This kind of behavior is on the other hand a respected quality of human nature at least in Finland but it raised feelings of helplessness on Jane. It´s about protection from danger, one of the key aspects of the attachment theory – how to protect Thomas when he himself is not capable of doing it.

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My purpose was to pay attention to the appearance of interactional moments of Thomas and Jane. I had an intension to create these kinds of moments and to give support to upkeep them by using different working styles. At the same time we tried to practice for example turn taking, concentration and waiting for a fun thing so that Thomas and Jane could have experiences of shared joy.

At the beginning of the sixth meeting of the couple therapy of Thomas and Jane I made a videotaping where the setting imitates the setting of CARE-Index. Because of the situation the toys were replaced by musical instruments but otherwise the setting was almost the same as the setting of CARE-Index.

VIDEOSAMPLE 3

As you could see the developmental progress of Thomas within six months was huge. At the time of this taping he was at the age of seventeen months. His vocal expression had a direction and he clearly wanted to say something. Thomas could express his feelings and you could notice purposefulness which is typical of his age. Thomas had a variety of facial expressions and he looked straight at Jane. Also the position was towards the mother. Thomas didn´t seek body contact but despite that he took the stick from Jane´s hand. Thomas seemed to have the choice of activity likewise the control. Actual interaction couln´t be seen.

Jane´s functioning seemed to be normal, wouldn´t you say? Although most of you couldn´t understand a word you could say that her vocal expression had different shades and she expressed her affections. A variety of facial expressions could be seen and Jane had an intension to have eye contact with Thomas. It also seemed like Jane would have been ready for physical body contact if Thomas had wanted it.

Jane had an intension to turn-taking and to the choice of activity but Thomas didn´t go along. Altogether Jane in my opinion had a constant and good intension to be in interaction with Thomas. Her attitude was longbearing and she was ready to try to take contact time after time.

It seemed to me that the problem was rather in the differences of temperament of the mother and child. It looked like Jane was all the time a little behind Thomas and that she couln´t reach the same level of power when it comes to action. One example of this was the situation were Thomas played the drum with the stick. Jane was a little terrified about the loud noise and even said about that to me but the noise

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didn´t seem to bother Thomas at all. You maybe also noticed that Thomas played the clockwork with the wooden side of the stick but Jane´s choice was the softer sounding rubber side. Jane wished to have feedback from me and we had a discussion of this session. I tried to encourage Jane to have more control on interaction and to have courage to meet Thomas at the same level of force in different plays. To my delight I could notice some changes on this matter already during our last meetings in music therapy.

3.2.4 Music therapy with whole foster family.

The meetings with the whole foster family included work with the different roles inside the family. The roles were observed in relation to existing interactional relationships but also through the changes Thomas brought into this system. The roles were reflected by picture making, improvisational playing, recording and listening and with the help of different contact making-plays and discussions. The purpose of these meetings was to pay attention to the family as a whole but also to everyone as an individual and as an important part of the family.

From the family´s point of view I understood that the most important thing in these meetings was this doing together –thing. And the family was eager to take part in different actions too. The doing was, however, from time to time even chaotic and the children seemed to have a strong need to compete the attention of adults. I felt this was correlating with the new situation in music therapy but also caused by Thomas moving to the family. I interpret their improvisation to the family with these words: “Family life is from time to time quite a mess because the family consists of so many different kinds of people of different age. Sometimes there are, however, also more accumulated moments like at the end of the improvisation when a common rhythm is found.”

4. The feedback from the processes I got feedback altogether from six families who had taken part in the kind of model I have now introduced to you. The feedback was mainly about the couple and family music therapy meetings. According to the families they had mostly felt easy to be in these meetings. The meetings were told to be unconstrained and structured enough. One parent claimed that music wasn´t the easiest way of expressing oneself and because the mother hadn’t felt so relaxed in the sessions.

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5. Conclusions about how the method works

The families were satisfied with the arrangements though one parent told that the long trip had been difficult to organize to the family. According to the feedback forty-five minutes once a week seemed to have been good but even twice a week meetings were suggested. Different kind of meetings and family compositions had felt fine. One family found that it had been very good that they could have decided what kind of composition they would come to the meeting because they themselves were the experts to evaluate that. Many parents also stressed how important it had felt when brothers and sisters could also join the meetings.

According to the feedback from the families, music therapy had

• • • •

helped to get to know the child better decreased jealousy of the sisters and brothers given information about the time when the child was living in the institution given an opportunity to use the same songs and plays at home as had been used in the institution

• given means to develop the co-operation with the child and • offered a place where it was possible to discuss with someone who had known the child during a longer period and get knowledge of the development of the child.

One feedback pointed out how important pre-information about music therapy is.

The knowledge about music therapy methods was thought to be particularly important for the families who didn´t consider themselves musical. Another family felt important that the therapist, at least in theory, was available even between the meetings by phone or email.

5. Conclusions about how the method works Without doubt ethical issues arise when the question is about an infant living in a child care institution and having therapy. Is there any use of therapy while the foster- or adopt family is still on search? The process is very hard even to the therapist.

The meetings are mentally but also physically very intense and therefore emotional bonds develop maybe stronger than in many other kinds of therapy processes. The feelings of counter-trasference are also markable.

Music therapy which is carried on when the child is temporarily staying in an institution would have great benefit if the people from the ward could engage them-

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selves in the process. In that case the task of the therapist would be to support and confirm the interaction between the child and the nurse. From the viewpoint of the attachment theory there is no idea to try to bring just another adult near to the child – the idea is to help the child and his/her nursing adult to attach to each other! The fact is also that a therapy process which is started during the child is temporarily staying in an institution is always a risk. The predictability is poor because no-one can know the exact length of the child’s stay. And of course there is neither no guarantee that this model I have introduced can be accomplished.

I have personally felt difficulties in this model in many cases. In the meetings which the child is taking part together with his/her foster parent it has been very difficult for me to make myself invisible. In these situations the child is often much more interested in me, the familiar person, than his/her new mother. I am the one who is singing and playing and am therefore also more interesting than a parent who is perhaps uncertain about the whole situation. My own feelings of insufficiency have popped up especially when I have met the whole family at the same time. At least I have learned that the meeting times have been all too short for the families despite the age of the children. Extra time is needed so that a peaceful being together becomes possible. On the other hand I have thought about an idea of having meetings just with the adults. Perhaps in such sessions it would be better possible to verbalize and reflect things that have happened during the meetings where the children have been involved. This idea might even become true because one of my fellow workers is studying to be a family therapist. Co-operation with family and music therapy would surely be fruitful to all the participants.

All in all I have a feeling that despite all the weaknesses of this model there is a clue which is worth following. Because of this clue I hope and believe that the developmental work will be continuing in this phase which is so important for the child and the foster family.

References Bowlby, J. (1988). A Secure Base. Parent-Child Attachment and Healthy Human development. New York. Basic Books.

Crittenden, P. (2001). CARE-Index. Coding Manual. Miami: Family Relations Institute.

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References

Goldberg, S.& Muir, R. & Kerr, J. (Eds.) (2000). Attachment Theory. Social, Developmental, and Clinical Perspectives. London: The Analytical Press.

Goldberg, S. (2000). Attachment and Development. London: Arnold.

Kalland, M. & Maliniemi-Piispanen, S. (1999). Vauvan kiikku. Kuvaus kokeilevasta perhetyöstä. Helsinki: Vammaisten lasten ja nuorten tukisäätiö. Edita.

Sinkkonen, J. 2001. Kiintymyssuhteiden häiriöiden yhteydet psykopatologiaan. In J. Sinkkonen & M. Kalland (Eds.), Varhaiset ihmissuhteet ja niiden häiriintyminen (pp. 146-173). Helsinki: WSOY. Sinkkonen, J. & Kalland, M. 2001. Johdanto: Ihminen tarvitsee toisten läheisyyttä ja turvaa. In J. Sinkkonen & M. Kalland (Eds.), Varhaiset ihmissuhteet ja niiden häiriintyminen (pp. 7-12). Helsinki: WSOY.

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Music Therapy Today, Vol. VI, Issue 4, (November 2005) a publication from MusicTherapyWorld.net

CHAPTER 59

You choose, you lose. A psychoanalytic music therapy approach with mentally retarded

adults with psychiatric disorders.

Van Reeth, Ilse

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Introduction This paper introduces my work at a ward for observation and treatment of mentally retarded adults with psychiatric disorders. I will particularly examine two problems which frequently arise in music therapy with these clients. The first one is the difficulty that many mentally retarded people have in making choices and decisions.

The second is their acting out reactions to the freedom provided by the therapeutic frame.

Description of the setting The psychiatric centre Sint-Amedeus (near Antwerp, Belgium) has an admission ward for observation and treatment of mentally retarded adults with psychiatric disorders, such as conduct disorders, personality disorders, psychosis, depression etc.

The ward consists of two units, of which one is open and the other closed. The maximum stay at the ward is about 1 year, but it can be extended at a related ward if further treatment is recommended.

Soon after a client’s admission to the ward there is a "music therapy screening".

During this observation session I try to estimate his musical experience and preferences, his capacity to play in a group, his assertivity and his musical memory. I attempt to gain a broad insight into the client’s picture. The screening also serves as a mutual acquaintance and a presentation of the music therapy. At the end of this session, the client chooses for himself whether he will participate in group therapy or not.

There are two music therapy groups. Both have two weekly sessions of 45 minutes each. For one group I determined more explorative therapeutic aims, as the group members have a certain capacity of self reflection. The other group is intended for clients with less ego strength, who demand a more supporting and less confronting approach.

If after the screening a client chooses to participate in music therapy, I try to find out - together with the ward’s therapy co-ordinator - which group is most appropriate for him. Due to the variety of psychiatric problems, these groups inevitably remain very heterogeneous in spite of the subdivision.

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Description of the problem

Whereas the setting of the ward is eclectic with behavioural therapy aspects, the music therapy setting is psychoanalytic. The clients’ concrete guidelines are the following:

• freedom of speech and musical expression, although not simultaneously (i.e. not playing any instruments while someone is talking);

• freedom of speech does not include insulting other patients (this restriction was imposed after severe conflicts that threatened to result in physical aggression)

• no physical contacts (this is a rule of life at the ward and is repeated in music therapy).

Description of the problem My work with these clients revealed some specific problems. In this paper I will focus on two of them: firstly, the difficulty that many mentally retarded people have in making choices and decisions; secondly, their acting out reactions to the freedom provided by the therapeutic frame.

The difficulty in making choices is most obvious in free improvisations. Soon after I started working with the clients of this ward, I learned that free improvisations in group sessions are far too difficult for them. For some clients, choosing which instrument to play is already hard to do. Playing together in a group even seems quite impossible, as many of them do not participate in the improvisation. If they do, acting out reactions such as leaving, yelling, throwing objects etc. are common.

Clients with the capacity to verbalise their feelings, describe discomfort, anger or annoyance afterwards.

Very often these feelings prove to be related to the musical expression or actions performed by other group members. When questioned about this matter, clients appear bothered by the restriction of their own musical and psychic space by the way other clients take advantage of the freedom of expression.

E.g. someone played very loud and one client got angry, saying that it gave her a headache. She left the music therapy room before I could even think about discussing it with her. Her leaving made me feel frustrated because I couldn't stop her.

Obviously this feeling was the projective identification with her frustration of being unheard in her musical expression.

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These problems are complicated by the heterogeneity of the music therapy groups.

In addition to their mental retardation, the clients' pathologies also influence their behaviour. Moreover, there are differences between clients in cognitive as well as socio-emotional development. One might even ask if group therapy is possible at all in these conditions.

Hypothesis A possible explanation for the difficulty to choose is the clients having not sufficiently learned to choose and decide: their cognitive limitations and, more important even, the retardation or stagnation of their socio-emotional development inhibited the development of their capacity to choose. This can be reinforced by the environment (family or staff) when taking over the client's responsibility.

At adult age, these clients' ego proves incapable of containing neither the freedom of decision (i.e. the consequences of decisions), nor the confrontation with other people's freedom. Despite the (conscious) enthusiasm about the freedom of speech and musical acting, this freedom generates a great (unconscious) anxiety to which the poorly containing ego responds by acting out.

TESTING THE HYPOTHESIS BY LITERATURE

The capacity to choose is not an "all or nothing"-capacity: it grows in accordance with cognitive development. E.g. a 2-year old toddler is able to choose whether he wants bread with cheese or marmalade, but he is not (or not yet) able to decide whether he wants to go to the swimming pool weekly from now on.

It is my opinion that object permanence, which is obtained during the sensomotoric phase as described by Piaget, is essential in choosing. The child needs a psychic representation of the desired object or the alternatives that can be chosen.

In a later phase, when the child is able to think in a logical manner and understands the connection between cause and consequence, he learns to imagine the possible consequences of his decisions - up to a certain level. Formal and abstract thinking, necessary for making more difficult decisions, is obtained by normal children around the age of 12 years. With many mentally retarded people, however, cognitive development stagnates before this level has been reached. Consequently, we must not expect them to be able to make these kinds of choices.

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Hypothesis

Not only cognitive development is significant in the field of choosing; socio-emotional development might be even more important. According to Do en it is possible to observe a discrepancy between the achieved level of cognitive development on the one hand and socio-emotional development on he other. This discrepancy is one of the reasons of conduct disorders or psychiatric disorders which lead to admission to the ward. Many clients manifest psychiatric disorders as described by Do en in case of a stagnation or deviation in the first socialisation phase. The primary social bonds did not generate a sufficient sense of basic safety, which is necessary in becoming an autonomous person. We can observe psychiatric disorders related to a stagnation or deviation in the first individuation phase as well. Major separation fears (caused by the lack of basic safety) hindered the individuation process. This results in a conflict between two things: one is the urge for exploration and the consciousness of the power of ones own will; the other is the dependency on the caretaker.

The escape from choosing in a larger context has already been mentioned by Freud.

He writes that the unconscious choice of not choosing leads to neurotic disorders, which offer the easiest solution to a psychic conflict in the economical way. The disease prevents the neurotic from choosing - and losing. Many of our clients are admitted to the hospital for reasons of "conduct disorders", mostly with an aggressive component. These (conduct disorders) are the client’s reactions to situations that require a maturity he does not have and a responsibility he cannot take. At the basis of these situations we often find choices which are impossible for the client to make and which frequently deal with loyalty. The psychic conflict thus exceeds the client’s strength and conduct disorders arise.

In this context, Fromm’s opinion on "fear of freedom" can be useful as well.

Fromm describes how fear of freedom can be understood as a fear of loneliness; one that is inevitable as the person undergoes a process of individuation. The more the primary bonds are broken - as a result of the child’s physical, psychic and emotional strengthening - the more he will be on his own, separated from the others, responsible for his own actions. Those of our clients whose growth was delayed and didn’t lead to sufficient ego strength, are not capable of dealing with this responsibility. (Exploring the origins of this would lead us too far, but of course we can wonder which part the upbringing environment plays in not breaking the primary bonds.)

According to Lacan, the concept of choice is essential in becoming a Subject: the impossible choice between the Being and the Sense. This choice, however, rather is a kind of "your money or your life"- choice. There is only one solution: choosing

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your life, and giving up all your money for that. As far as the Being or the Sense is concerned: one must choose the Sense, which brings a "lack of Being" with it.

The capacity to choose is related to the unconscious desire, which can only exist if the Subject has effected the symbolisation of the second level, thus: if the Subject has adopted the language as a metaphorical system. We notice an insufficient adoption with mentally retarded clients.

Rather than developing his own desire, the mentally retarded person stays in the position of meeting the Other’s desire. He exists as a fulfilling object of the Other’s desire. Leaving this position requires the capacity of mentalisation. Therapeutic reality shows us that our clients lack this capacity.

The capacity of mentalisation is also the clue to the acting out reactions. The musical expression of other group members, often fierce and not hindered by a controlling and regulating Ego, has a certain impact on the client. He cannot “experience” it, there is no signifier. In short, it leaves the door open through which the Real sneaks in. In an acting out reaction, the client slams this door shut, or at least tries to do so.

Therapeutic work with these clients often reveals a past of "passivity" as far as decisions are concerned. Because of the initial refusal to choose and their tendency to let others decide, mentally retarded persons plant or grow the idea that they have no capacity to choose at all. Family or staff (educators, mentors, teachers, doctors etc.), mostly with good intentions but maybe unaware of their own unconscious drives to install a relationship of dependency, reinforce these dynamics by taking over the client's responsibility instead of helping him to learn to choose.

In the last few decades, however, the prevailing pedagogic opinions have increasingly emphasised the importance of choice and participation for these clients. During my supervision I’ve become aware of my personal "standards" on this subject: I wanted my clients to have participation, I wanted to take them seriously. This is one of the reasons why I let clients decide whether they participate to music therapy or not. But maybe, at the moment they are admitted to the hospital, they aren't able to make this kind of decision yet...

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The value of music therapy

The value of music therapy It is my opinion that a central concept in music therapy is "containment" the way Bion formulates it. In musical improvisations the music therapist performs the containment function, in expectation of the client’s growing capacity to cope with the originally unbearable feelings. Guiding the client in his growth to containment is essential for the development of some sort of mentalisation that is necessary for making choices.

Furthermore, music is a very appropriate medium to practise the making of choices.

The choice of an instrument or a way of playing have few if any consequences: the consequences of this choice do not last longer than the end of the session, and mostly not even that long. The client can also reconsider his choice of participation in music therapy.

Structuring the improvisations is often necessary in the first period. Mary Priestley’s opinion on musical structure in improvisation is that it can partly take the place of the ego’s synthetic functions. It seems, she writes, that when a certain structure is advocated in analytical music therapy, it allows the client a superego cleavage whereby he accepts the boundary of a given structure as a partial superego. The musical structure releases the patient’s own hold on some of the repressed material and allows this to surface in his mind during the improvisations with or without it being expressed in the music.

In this context, the task of the music therapist is to steer a path between no matrix for expression and a structure that is crippling rather than enabling.

In view of the problems generated by the making of choices, in my approach I developed a strategy which, starting from a certain restriction (by means of a structure), gradually increases the freedom of choice. At the same time the clients are supplied with "musical tools", which they can utilize afterwards to form their (free) musical expression. Supplying musical possibilities I try to meet the client’s often minor initiative of exploration: there is no own desire, so why explore the world?

This brings us to the containment function again.

This strategy will be illustrated by means of the following case study, which describes music therapy with a group during 8 weeks. The group members have a certain self reflection capacity. As described before, there are two weekly music therapy sessions of 45’ each; one session is for active music therapy, the other is for listening to music. Not all sessions are described.

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Case study Due to several circumstances only 2 group members are present during 8 weeks.

Then one of them is redirected to individual therapy for specific reasons, so there is only 1 person (a young woman, K.) left in the group. She enjoys this unexpected “individual” therapy.

1.

After two weeks, another woman, D., joins the group. The 2 women have the difficult relationship with their mothers in common. Furthermore, both show little empathy to the other group member and they struggle to get the therapist’s attention. They are not able to play music together: each one plays on her own and there isn’t any connection or coherence.

As the clients clearly do not experience any support or satisfaction in these improvisations, another approach is chosen: dyadic improvisations during which the therapist plays together with one group member at the time. The clients choose the instruments they play. During these dyadic improvisations, the non-playing person – alternately K. and D. – manifests particular behaviour such as a theatrical pretension to be asleep, stealing a pen from my desk etc.

Group improvisations, even with only 3 persons, seem to be impossible for these clients. They are too much involved with their own concerns to listen to each other – and so is their mutual musical response. Maybe the confrontation with “the Other being different to the Self” is too frightening. In dyadic improvisations (in which I play the supporting role), both clients appear to be more at ease. It feels like a moment of comfort in a turbulent day. However, it is remarkable how they cannot bear the therapist paying exclusive attention to the other group member.

2.

A third woman, N. joins the music therapy group. She is suffering from alcohol abuse in a troubled relationship with her children, of whom one is autistic,. She usually starts the session by saying that she’s having a hard time, that her head aches and that she is not good at making music.

The next session only K. and N. attend to music therapy. N. (the client having difficulties in being a mother) enters the room saying she has a headache. K. (the one having difficulties in being a daughter) says that she feels bad, that no one understands her, no one cares for her etc. She wants to leave the music therapy room to “take a breath outside”, to go to the toilet, to wash her hands, in short, for any think-

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Case study

able reason. She wants to return to the ward and her constant complaining and yelling makes therapy impossible. In spite of my usual approach I intervene in a directive way and subsequently K. stays with us, although not participating in the improvisation.

As N. – who claims her headache has increased by the yelling – does not want to play any instrument either, I play the piano while the clients listen. Doing so, I intend to reinforce or emphasize the transitional space within which the music takes place; I let the music itself invite the clients to participate.

3.

In the following session, K., D. and N. are asked to play solos with a certain metre.

K., very sad this time and crying instead of yelling, at first does not want to play.

After having left the room for a moment, she participates in the improvisation. The structure of the improvisation is as follows: every participant picks out a “drum” (any membranophone). I start to play a metre; the clients improvise with it alternately. The available time per person is restricted to 2 bars. Unexpectedly, the clients add more structure to their improvisations, like repeating a small rhythmic cell.

The therapist playing the metre and counting from 1 to 8 (2 bars in 4/4), serves as a support. The restriction of instrument choice and improvisation time is meant to reduce the freedom, and as a consequence the fear of playing. The instant effect (the structure added by the clients), although surprising me, seems to prove the value of this approach.

4.

The following session is the weekly receptive music therapy session. We use 4 pictures of the “basic emotions”. Every client gets a coloured card which has to be put together with the picture in accordance to the music; we listen to various pieces of music.

The task invites the clients to focus on the emotional aspect of music. Moreover, the music is performed by others and as a consequence, it expresses an emotion that is possibly not theirs at that moment. This task reveals the problems that some mentally retarded clients have in linking music to emotion and in imagining other persons’ emotions. Maybe there is not enough theory of mind?

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5.

In the next two sessions, two new group members join the group. E. is a young woman who is still her parents’ “little girl”. R. is a jealous man with aggression problems towards his partner.

6.

N. starts the session by saying she has a headache. I propose an improvisation on melodic percussion instruments (because they sound softer). D., who planned to play the conga, gets very angry and leaves the therapy room slamming the door.

Subsequently she paces up and down in front of the windows so that we can see her.

We play the melodic percussion instruments (there are 6 of them and all clients pick out one rather easily); during the improvisation we vary musical parameters such as loudness, tempo, number of notes, range etc.

After that, I propose that everyone freely chooses another instrument. This appears rather impossible – both clients keep doubting – so the range of choosing possibilities is restricted again: they have to pick a “drum” (membranophone). Both clients do so. Then we make an improvisation in which I start with a metre which has to be copied (as well as possible). Afterwards, I propose various ways to play cloaked in a game: a small contest of playing loudest, softliest, slowest, fastest, like a robot, a loony. We continue the game but this time the clients propose the ways to play.

N.’s headache keeps the other clients from choosing freely. We observe different reactions with the other clients: K., E. and R. find it easier to pick an instrument out of 6, while D. cannot stand being restricted. She is not able to verbalise this and leaves.

Proposing various ways to play, I want to help the clients to discover some of the possibilities offered by music. The aim is that afterwards – i.e. after a long period – they will make use of these “musical tools” to build an improvisation themselves.

The next step is the clients proposing how to play in a game-like improvisation: as they focus on the “game” they feel free to make use of their imagination and creativity.

7.

The clients are invited to illustrate a story by sounds. Every character in the story is presented with a specific instrument, and the events, emotions etc. are all played by the group members. They have a lot of fun doing so and they dare to exaggerate the expression of the characters’ emotions.

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References

The story enables the clients to express emotions using instruments without getting overwhelmed: it is a role they play, a story, not their own feelings.

8.

In the last session of this case study – the work with these clients has continued since then – the group is invited to make a free improvisation. Although they still need some verbal support of the therapist, they succeed in choosing an instrument and playing without the therapist telling them what to do. The major part of this improvisation is rather chaotic, but once in a while some measures of interaction (by means of a common metre, adaptation of one’s own volume etc.) occur.

It is evident that we cannot expect the clients to fully accomplish the huge task of second symbolisation in such a short period of time. However, the scarce moments of really playing together in a free improvisation prove that they are able to enter the position of Desiring Object. Moreover, the clients encourage me to continue my job, for they are fascinating and gratifying to work with.

References Demuynck, J. (1992). Kunst door gehandicapten. Gehandicapte kunst? Psychoanalytische Perspektieven, 17, 19-28.

Do en, A. (1990). Psychische en gedragsstoornissen bij zwakzinnigen. Amsterdam: Boom.

Fromm, E (1976). De angst voor vrijheid. De vlucht in autoritarisme, destructivisme, conformisme. Utrecht: Bijleveld.

Kohnstamm, R. (1993). Kleine ontwikkelingspsychologie. Houten / Diegem: Bohn Stafleu Van Loghum.

Priestley, M. (1994). Essays on analytical music therapy. Phoenixville: Barcelona Publishers.

Van Neygen, A. (1994). Positie en structuur van het subject over de "Neurosenwahl". Psychoanalytische perspectieven, 24, 9-25.

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Music Therapy Today, Vol. VI, Issue 4, (November 2005) a publication from MusicTherapyWorld.net

CHAPTER 60

Steering a path through change; observations on the process of training

Watson, Tessa University of Surrey Roehampton and Ealing Primary Care Trust Contact: Tessa.watson@roehampton.ac.uk Symposium II: Aspects of the Music Therapy learning and teaching experience in the UK

Proceedings of the 6th European Music Therapy Congress

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Students these days tend to be very much better informed than I was, when I applied to train as a music therapist. There are enough books to read and enough introductory courses to attend to find out what music therapy is. But even the best prepared student can be challenged by the amount that the training will change them personally. Through the process of learning to help other people to change, they must also be helped, and change, themselves. One student told me; ‘I think change is in itself frightening for people. We cling onto our weaknesses as much as our strengths because they define us. I think there is a fear … of a loss of identity.’

In this presentation I will be thinking about the challenges that students face when they train, and how these challenges provoke change. I will start this presentation with two quotations about change.

‘Men do change, and change comes like a little wind that ruffles the curtains at dawn, and it comes like the stealthy perfume of wildflowers hidden in the grass.’

(John Steinbeck, Sweet Thursday).

This first beautiful quotation is from John Steinbeck, who wrote so much about change and internal struggle. I like this quotation because it seems to me that change often can come like a little wind that ruffles the curtains at dawn or like the stealthy perfume of wildflowers hidden in the grass. Perhaps it comes upon us in a way that seems very insignificant or for a reason that we cannot identify. Perhaps for each of us there are moments hidden in the experience of training that trigger a change in us. We may only realise the impact that this change has had on many aspects of our lives or our work when we look back. And many of us feel the need to carry on our personal development to continue the change that the training has begun.

My second quotation, from a final year music therapy student, holds all these thoughts and ideas.

‘Change takes time (usually). Sometimes it comes unexpectedly when one stops trying to change and takes things easier. Things might change in us so subtly that it is difficult to realize that change has taken place… It takes courage, strength to change something unpleasant or something that burdens you. Change can be creative and cathartic, could imply progress. On the other hand sometimes when we change we leave something behind, we also have to make some sacrifices or compromises.’

Very little has been written about student experience during music therapy training, and yet it is something important to know about. Perhaps as students or newly qualified therapists, we don’t feel confident enough to write about our experiences, and

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as we become more confident, we are further away from the experience. Perhaps it is also important to consolidate some of the intense experiences we have had during training, before trying to put pen to paper. Judith Webster, writing in 1992 in the British Journal of Music Therapy said that ‘Music therapy training unlocked the door to a world of self-awareness and self discovery which I had never imagined to be so revealing, so painful but also exciting.’ 1988 (BJMT Vol 1 No 2 p18).

I imagine that this quotation has resonance for many of us. How many of us, when we began our training, were aware of what we had ‘let ourselves in for’? As I wrote this presentation, I began to think back to my experience of training. My training at Roehampton provided me with many profound experiences – some difficult, some positive. I’m not sure that I made sense of some these experiences for a long time…

And now, I have both the privilege and the challenge of training students at Roehampton, and I witness many changes in students. Sometimes training is a difficult process; at other times it seems that students embrace and revel in their change.

Through my experience of teaching, I have become particularly interested in the way in which students experience change during training, and how the tutor has a role in this change and can enable it most positively. How does the teaching and facilitation, and thus the learning, on a training programme, have an impact on student change? Over the past few years I have asked some students these questions and I am very grateful to be able to use their responses in this presentation. I would like to consider some of the challenges that students experience during their training that can provoke change. I’ll refer, as I go, to some theories of learning and teaching that might help us to understand the student position.

The kind of learning that takes place on a music therapy training is personally challenging in many ways. It involves taking in new knowledge but it also involves consistent challenges to the student’s own conceptualisation of their world. We are a reflective profession, deeply engaged with change in our work; it is inevitable that becoming a therapist will involve change for ourselves. I hope that as you listen, you will be able to engage with this presentation as having relevance to you; whether newly qualified and close to the process of training, or a therapist of many years experience, for whom the memories of training are faded.

In the UK, training courses have, over the past 15 years, changed significantly. We are now state registered and there are professional competencies which music therapists must meet, and thus a comprehensive syllabus to be studied. Our students must, of course, develop their musical skills in order that they can use their music to help their clients, and must develop a sound therapeutic approach. But there are also other qualities that all therapists need. Both McConnaughy and Rogers talk

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about the person of the therapist in clinical practice. We need to be genuine, caring and have empathy. We must be self aware and self accepting (though not perfectly analysed…), have a solidly structured sense of self, and a wish not to become a ‘finished product’. When we think of this, we can see how much the tutor and the student share the responsibility for student development and change. Tutors can dictate what a student must know about, but the student must be motivated and able to develop their own personal qualities.

And every student who embarks on a Music Therapy training is unique. Each student brings extremely different knowledge and experience; personal, academic, musical and their work with different groups of clients. Students have told me how their work experience and personal experience has provided them with useful knowledge to bring to the training; one student stressed the way in which her engagement with music had given her a creative resource that could sustain her through challenges and difficulties on the training. Students are encouraged to share and use this personal and work experience and knowledge in order to engage with, and make sense of their learning.

On a music therapy training we learn in different ways. There is a lot that we have to learn about (child development, child psychology, psychiatry, and theory – both of music therapy and at Roehampton, of psychoanalysis). This kind of knowledge, knowing about things, is termed declarative by John Biggs (1999). But we need students to have functioning knowledge as well; this means knowing how and why to do things. So almost immediately, we plunge students into experiential learning.

On the Roehampton course, in the first term, students go out on visits to different workplaces, and learn straight away about how they might need to react in difficult, sometimes painful or awkward situations. Students begin their clinical improvisation classes and have to struggle with the challenges of trying out a new way using their music differently, often observed by other students who offer (mostly) well meaning constructive criticism. Students have to find a mother and baby to observe, an experience which can bring up memories of their own early lives.

Importantly, they must also find their own personal therapist. In the second term, students embark on their first clinical placement. They are immersed in a wide range of different, intense experiences.

When students realise that they are required to explore their own ideas and construct their own knowledge, as well as learn through lectures and seminars, and when they realise that change and the unknown are welcome, they can begin to feel less, rather than more sure about what music therapy is and what they are embarking on. They can also feel worried when they realise there are no definitive answers to all their questions. Tutors may even sometimes say that they ‘don’t know’.

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John Woodcock’s observation is apposite here. Talking in 1992 in the BJMT debate about priorities in training, he says: ‘Change is inherently painful, as well as joyful, even the change in one’s concept of what music itself is.’ (BJMT Vol 6 No 2 1992 p23). And Elaine Streeter, writing about experiential music therapy groups reminds us that ‘there are some profound experiences of loss (as well as growth) involved in training to be a music therapist.’

Do music therapy students also feel this sense of loss and growth about the process of training? I would like to read some responses from students where they speak of the painful or difficult parts of the process, as well as the ways in which they feel they have changed positively as a result of the training. Some of these quotations allude to the way in which the training reaches right into our personal, private lives.

One student said; ‘Confronting difficult things from my past in personal therapy was difficult but proved a very worthwhile endeavour. Conflicts in training group were also challenging but ultimately helped me to learn more about myself. … As I started to look at difficult feelings arising from my own life, and to think about the difficult feelings of clients, I felt more vulnerable and fragile. As a result I gained a considerable amount of weight through comfort eating. … As a result of the process, I got rid of things in my life which were not healthy – especially relationships and habits which no longer served me.’ This student added that: ‘I now take more care of myself physically, psychologically and emotionally.’

Another student wrote; ‘I think I might be less ‘fun’ than I was a couple of years ago, but this probably comes with greater responsibility… might be a question of maintaining a balance in the future. She added that ‘I am much more self-aware.

More confident and expressive, with greater sensitivity to other people’s feelings in my personal relationships. Greater understanding of negative/destructive elements of relationships and able to deal with them better. I think it’s surprised me how much I (and other students) have changed and so I think I’m more aware of the possibilities for change in other people.’

A third student talks about her steady, gradual process; ‘My learning has been very gradual. My understanding has gradually increased as the course progressed. I feel that the journey has been growing into a therapist rather than just becoming one, and will continue as and when I work. It isn’t at all about facts. Everything I have learnt on the course is new. I feel like a blank canvas that has absorbed the experience of the past years… And this student gives us a warning too – that using psychoanalytical theories in personal arguments is not recommended! I partly mention this last part of the student’s response because the way in which our personal lives are affected by our training is significant. Students may be concerned by the way in

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which their newly acquired vocabulary, ways of thinking or personal growth, mean that they no longer fit in so comfortably, or in the same way, with groups of friends, family or even partners. Rachel Darnley-Smith talks about this in the British Journal of Music Therapy in 2002. ‘Trying to speak this new therapy language with old friends and family was not a success. ‘Music therapy’ sounded very interesting, but a therapist who talked about herself and her feelings, as well as the work she was doing with clients, provoked responses along the lines of ‘we’re not in one of your sessions now’.’

Perhaps we can all remember how difficult it was to try and integrate this new way of being, thinking, seeing things, responding to situations. Friendships are tested, relationships fall apart, family wonder what on earth has happened to the sister, daughter that they knew. It takes time to find a way of including our new knowledge in our everyday lives.

I asked my students what was striking for them about the way in which they were taught. It seems that students often find that the way that they are required to learn is very different to their previous experiences. One student said: ‘Much of the training had to be experiential which was very different for me. There was also much more student participation in talks and lectures. This training was much more of a personal journey or process. Nothing I have done before has involved so much personal development and reflection on one’s own feelings and responses.’

Experiential learning is essential on a music therapy training, and I would like to speak more specifically about this now. This kind of learning has been described by theorists for many years. Kolb (1984) drew a learning sequence, or cycle, to show how he thought it worked. Many theorists think that experiential learning is the most useful type of learning in all types of situations, because students are active, taking responsibility for their own learning, and can relate and apply it to their own experiences and context. The phase of reflection is felt by some theorists to be the most important.

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FIGURE 1.

Kolb’s learning cycle

Actually another theorist, John Dewey, thought about this process as a series of spirals rather than a circle. Each spiral, or episode of experience, allows potential for change and growth. Interestingly, Dewey also thought about timing, and how it was important to have time to consider one’s experience, but not so long as to become stale. As tutors, we are often debating the right time to introduce a new idea or experience; a little as Winnicott thought of object presenting. And we know as therapists the difference that a break, a pause, can make to the therapy process.

In 2003 I completed my post graduate certificate in learning and teaching in higher education. This was an interesting undertaking, because it meant that I was a student and a lecturer at the same university; in the position of student and teacher at the same time. I studied theories of learning and teaching, in order to apply them to my work with students. Perhaps, looking at Kolb’s learning cycle, some of you are making the links that I kept making, throughout my study. Theories of learning, especially experiential learning, echo the process of therapy. Should I have been surprised to find the words and ideas of Yalom, Bowlby, Bion, Foulkes and Rogers scattered among the pages of my text books as I studied? Therapy, after all, involves learning - about oneself.

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Someone who brought together thoughts about therapy and learning rather neatly is Carl Rogers. As therapists, we tend to know about the part of his work which he termed client-centred therapy. However he also thought a good deal about teaching and learning. Some of his 10 principles of learning, rather paraphrased, have much to say to us as Music Therapists, as well as to students and tutors;

• Learning which involves change in self-perception is threatening and tends to be resisted, hence learning is more easily achieved when external threats are minimised and experience can be processed safely.

• Learning is facilitated when the learner participates in the learning process and much significant learning is achieved by doing.

• Self-initiated learning which involves the whole person, feelings as well as intellect, is most lasting and pervasive.

• Creativity, independence and self-reliance are facilitated when self evaluation is primary and evaluation by others is secondary. (Brockbank and McGill p148)

My students’ responses support these ideas. When asked what helped them to move along their process of becoming a music therapist, students said this; ‘Getting out to my placements and experiencing theories in a ‘real’ clinical setting brought them to life for me.’

And ‘[The] experience of the idea being translated in the actual therapy work [has helped me to change]. Sometimes one needs to see or feel something happening before one can take it on board.’

‘I can remember, at the beginning of the course, experiencing at first hand how the mother/infant relationship relates to the therapist/client relationship, and how this helped me to move along the process of becoming a therapist.’

So experiential, personal learning is very important to the process of change. But this kind of learning also carries with it risks and difficulties. Students also told me about their need to feel safe enough to take risks – and the difficulty of feeling judged. Talking about one experiential learning module that focuses on the clinical use of music, students said ‘I wish I’d been braver’, and ‘I wish I’d taken a risk’ These students’ honest answers helped me to think about, and develop the ways in which I can better support their process of change. Perhaps paralleling a therapy group, it seems clear that this kind of student learning session must feel safe and supportive if students are to be able to make themselves vulnerable, expose their worries and areas of weakness, and learn from others.

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So why use experiential learning if it can be so painful? What does experiential learning allow students to do? As our students have already told us, it helps them to bring learning to life; to construct their own meaning and thus learn ‘deeply’. I would like to speak more specifically about this for a moment.

In teaching, there is often a moment when students get to grips with an idea, and need to try out their knowledge. This might be the point in a seminar where I ask if there are any questions. Someone is brave enough to say ‘is it like this?..’ and state their own understanding. Or, we are in repertoire group, where the students bring musical difficulties or problems from their clinical work. We have thought about a student’s problem and I ask for someone to role play the therapist and the client.

There is a silence, and a couple of students are brave enough to say ‘yes, I’ll have a go’. Or we are thinking together in supervision and a student bravely makes a link between a theory and some case work.

Students need a feeling of safety in order to engage in this process. They are taking risks, journeying outside their realm of experience to develop their understanding, make links and construct their own meaning of a concept. They are, in the process, making a change to their knowledge and sometimes their attitudes and beliefs. I like the concept of ‘single and double loop learning’ that describes this (Argyris and Schon 1978).

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FIGURE 2.

single and double loop learning (Argyris, C, and Schön, D 1978)

Double loop learning involves learning from mistakes and in the process, questioning and modifying underlying ideas or beliefs. It enables a personal learning shift, allowing students to journey further in their development. Here we find another link with therapeutic theory; this idea links with that of Foulkes (1964), a group analyst, who described the idea of a ‘reflective loop’, where patients in group therapy can journey outside their area of comfort, and come back to the group, having been supported in learning something about themselves. Students who are used to more didactic teaching can be quite unfamiliar with this type of learning, and need support to develop their confidence and skills in this setting.

When students take a risk and contribute to group learning in a way that links their learning and their experience, they are making a transition from declarative to functioning knowledge. But this process can be tinged with anxiety. Savin-Baden, an Occupational Therapist by profession, terms this part of the student process disjunction. She defines this as ‘A sense of fragmentation of part of, or all of the self, characterised by frustration and confusion, and a loss of sense of self. This can result in anger, frustration, and a desire for ‘right’ answers.’ (p87 2000). Disjunc-

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tion can occur as students are in transition, learning about new concepts and ideas and making sense of them from their own experience. And tutors are not always able to provide students with ‘right’ answers, particularly in relation to their clinical work.

Savin-Baden feels that if students don’t resolve disjunction positively, the issue that caused the disjunction will continue to inhibit their progress. There is, again, a parallel with therapy here. Savin-Baden identifies, and I have observed, different ways of resolving these difficult feelings; retreat (don’t engage with it), temporising (postpone engaging), avoidance (find a way of getting round it), or engage with it; usually through a reflective process. To illustrate this, I would like to read an extended quotation from one student, who looks back on the difficulties she experienced during her training: ‘Change is the stuff of life, but it also involves loss and it still feels painful. I think a significant change must have been at the end of the first year, when I argued about a mark – a lot of my self confidence was held in the idea that I was good at this subject, and if I was not recognised, what must I do with my self-concept? I nearly dropped out. Not there and then, but through the long, silent summer. Change this big feels like dying. It is so painful, almost anything else would be preferable. My tutor said to me in assessment ‘you either understand straight away and well, or not at all. You need to find a way of making it all, right enough, a middle ground that’s good enough.’ In the end, I recognised that the fantasy ‘I’m brilliant really, I just need to find the right context’ covers the fear; ‘I’m crap, really. And people know it.’ – and the change is to realise I’m neither – what a relief to find that I’m ordinary… but what pain and loss too. I feel more boring now. [At the time] I was furious. For a long time I maintained (and on some verbal level it may be true) that my tutor had misunderstood me. But the fact remains that she put her finger on exactly what the problem was.’

This is an example of how an assessment can touch on deeply personal issues that must somehow be addressed and resolved between tutor and student (and probably in personal therapy). This student was being asked to address a deeply held, keenly felt ambivalence; am I brilliant or am I crap? She talks of retreating (thinking of leaving), avoiding (my tutor has misunderstood me) and then of engaging, and of managing a change that might ultimately help her to help others. I find this honest account moving and convincing evidence of the challenge that students take on when they engage fully in the training process.

It may not be possible, nor desirable (as in therapy), to make things feel alright, or easy for students. But it is important to hear and learn from students about what

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supported their process of change. As might be expected, individual students identified different elements of the training as being most supportive, but supervision was frequently mentioned; ‘The most profound [teaching support] has been a couple of key moments in supervision when I was made aware of things I was doing in the sessions that I wasn’t aware of. This has led to very definite changes in the way that I work.’

‘I think supervision has made a great difference, helping me to move along.’

This emphasis on supervision as being identified as a key element of teaching and support underlines the importance of the UK post diploma supervision scheme, and of supervision for all our development.

Students also talk of their personal therapy providing them with an essential place for reflection, and to make sense of some of the disjunction that they are experiencing. One of my students, talking about personal therapy, said that; ‘it supported me during difficult times, and helped me to face some of my difficulties. Moreover it helped me to acknowledge some of my needs. It also helped me to become more patient as a therapist, since I saw within myself how difficult it is sometimes to change certain things.’

We teach a syllabus that includes all that is required of us by the UK Health Professions Council, and that includes all that we feel trainee therapists need to know, and still we require something extra from the student. We want them to learn what they, personally, need to know in order to practice as a competent therapist – and this personal learning is different in each case. We thus encourage students to reflect on their process in the training and to address areas of weakness.

As a tutor, I cannot make this process easy, as perhaps at times it was not easy for me, but I continue to work to support students in the best way. I am always inspired and impressed by the hard work of students on their personal journey towards becoming a music therapist. It is my conviction that it is now time to involve students and tutors in in-depth research and study into this complex area of pedagogy.

I would like to end as I began, with two quotations. Firstly, T S Eliot from the Four Quartets, to which I was introduced by Andrea Clifford, when I was training; ‘We shall not cease from exploration And the end of all our exploring

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References

Will be to arrive where we started And know the place for the first time

Lastly, a quotation from a second year student about to take his final assessments; â&#x20AC;&#x2DC;I think I welcome change more now. I used to be very frightened of, and resistant to it when I was younger. I now feel that it is not only easier to manage change in my life, but that change is an exciting and desirable part of a full life. Change for me was always experienced as a difficult loss. I now see it as an opportunity for growth and development, not to mention adventure!

I would like to acknowledge and thank the students who have generously shared their experiences through the completion of questionnaires

References Argyris, C., & SchĂśn, D. (1978). Organizational learning: A theory of action perspective, Reading, Mass: Addison Wesley.

Darnley-Smith, R (2002) The journey through a barren landscape to practising music therapist. Three peer responses. British Journal of Music Therapy, 16, 2, 7980 Jacques, D. (2000). Learning in groups, London: Kogan Page (3rd edition) Kolb, D. A. (1984). Experiential learning. Experience as the source of learning and development, USA: Pentice Hall.

McConnaughy, E. A. (1987). The person of the therapist in psychotherapeutic practice, Psychotherapy, Vol 24 No 3 Rogers, C. (1983). Freedom to learn in the 80s, USA: Bell and Howell Company Savin-Baden, M. (2000). Problem based learning in higher education: untold stories, Buckingham: Society for Research into Higher Education

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Streeter, E. (2002). Some observations on music therapy training groups. In A. Davies, & E. Richards (Eds.) Sound company. Music therapy and groupwork, London: Jessica Kingsley Publishers Steinbeck, J. (1954). Sweet thursday, Penguin Books Warner Weil, S & McGill, I. (1989). Making sense of experiential learning, Buckingham: Society for Research into Higher Education Webster, J (1988) Music therapy training: a personal experience. British Journal of Music Therapy, 2, 2 Woodcock, J (1992) Priorities in the training of music therapists; meet them where they are. British Journal of Music Therapy, 6, 2, 25-26

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Music Therapy Today, Vol. VI, Issue 4, (November 2005) a publication from MusicTherapyWorld.net

CHAPTER 61

Good vibrations: musics impacting child bedtime milieu behavioral patterns

Wesley, Susan Bray PhD, MT-BC, NMT Acadia Psychiatric Hospital - Bangor, Maine USA Decreasing child patient anxiety around bedtime, especially when it leads to aggressive behavior, is an ongoing issue in many hospitals. This study examined the use of planned music interventions for assisting patients to be less anxious at the bedtime hour, therefore, reducing patient aggressive behaviors resulting in therapeutic holds and/or restraints. Key terms: acoustical design, inpatient children, psychiatric hospital, Vagus nerve, music

Observations based on â&#x20AC;&#x153;everydayâ&#x20AC;? sounds in hospitals Sound/noise studies in hospital settings has been studied increasingly over the past decade, with particular interest in medical hospitals given to neonatal intensive care units. As a result, equipment modifications have been made because of inappropriate decibel levels; staff traffic patterns have been altered; and care-givers' aware-

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ness has been heightened as to loudness of "voice levels" at certain times of day and night. Psychiatric hospital settings have most often been studied for sound/noise levels information mostly around the issues of agitation in elders particularly related to "sundowners" phenomena. Since 2000, the number of journal articles that discuss the impact of noise (ambient sound) on patient care has slowly increased. PubMed catalogs seven titles from 2000-2002 but approximately one per year prior to 2000. Architectural interests have also grown albeit incrementally over the past three years.

Susan E. Mazer introduces the obvious in her article Sound Advice: Seven Steps for Abating Hospital Noise Problems (2002). "If we take for granted that hospitals are institutional and designed to be “one-size-fits-all” kinds of places, then their physical character can appear to be generic. However, while the hospital environment is most commonly thought to be about beds, walls, windows, floors, ceilings, and technology, it is also about people, clutter, and noise. In fact, according to patient satisfaction surveys, the quality of the healthcare experience is often evaluated according to the quality of the hospitalÕs dynamic environment, which is circumstantial and changeable." Mazer continues her discussion by describing seven steps for defining a more "patient friendly" ambient environment.

• • • • • • •

Step 1: Assess the Sound Environment Step 2: Establish Sound Standards Step 3: Establish Equipment Maintenance & Purchase Standards Step 4: Make Decisions About Patient-Appropriate Equipment Step 6: Design Areas for Sound Control Step 6: Educate Staff Step 7: Measure Results

The second Congress of the International Academy for Design and Health Congress held in Stockholm in 2000, provided an opportunity to raise several questions on many of Mazer's suggestions. One particular paper at the Congress, presented information related to the likelihood that ambient sounds found in a psychiatric hospital setting could be triggers for negative behavior in patients (Wesley, 2001).

It also presented particular music therapy strategies that were designed for maximizing therapeutic intent and decrease specific behaviors for selected patients. The study suggested that environmental or ambient unit sound is likely overlooked as a patient stressor and therefore, was not factored into treatment planning.

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Observations based on â&#x20AC;&#x153;everydayâ&#x20AC;? sounds in hospitals

Auditory over-stimulation is an especially valid concern given the premises of Porges' Theory of Social Engagement (1998). This theory links the evolution of the autonomic nervous system to affective experience, emotional expression, facial gestures, vocal communication and contingent social behavior. It is sometimes referred to as the "Polyvagal Theory" and proposes that the evolution of the autonomic nervous system provides an organizing principle to interpret the adaptive significance of an individual's affective processes. Most importantly, in a particular physiological state the range of behavior is linked to psychological experience for the individual. The Vagus Nerve or Cranial Nerve 10 (CNX) is 80% afferent although it is more commonly regarded for it's efferent (20%) influence on human functioning. In order to understand the "job description" of CNX it is important to know that its Sensory Branches include the meningeal, auricular, pharyngeal branches and the internal, external and recurrent laryngeal branches and the Visceral branches of the Vagus include the aortic arch barorecpetors, heart, lungs, and abdominal organs. (insert chart a & b side by side) Informed specifically by his work with trauma survivors and the Polyvagal Theory author and clinician John Chitty has provided further clarification of Porges' work.

Chitty refers to his integration of information as the "The Triune Autonomic Nervous System" and emphasizes a Phylogenetic view of the vagus as it pertains to the evolution of living organisms in general and humans in particular (2002). Keep in mind that the Autonomic Nervous System (ANS) is the neuro-endocrine-immune structure that enables survival and has two branches: parasympathetic (rest/rebuild) and sympathetic (fight/flight). The third of the "triune" is where Chitty aids the understanding of the Polyvagal Theory. "Porges has shown clear evidence of a third, more modern branch of the ANS, with a survival value specific to more sophisticated animals especially primates "Social Nervous System" is the proposed term for this third branch of the ANS." Further, Porges' research shows that under stress, the human system tries its newest system first. When that fails the next older system comes "online". As the system of last resort, the parasympathetic resources are employed. Under stress, therefore, the order of survival strategies goes: (1) social/relational; (2) fight/flight; then (3) immobility. Chitty has also documented, through his clinical work, that in the case of human trauma, the capacity for using newer strategies can be eroded with the older strategies becoming the normal response.

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Patient responses to hospital sounds An eight-week individualized Music Therapy plan incorporating premises of the polyvagal theory, was developed for three patients, in order to reduce their assaultive behaviors. The three boys were referred because of their observed enjoyment of some music activities and the severity of the aggressive behavior. The hypothesis was that if a patient's "memory menu" could also include substantial positive associations based on organized auditory input or music interventions/experiences then the patient might have more options for positive behavioral responses from which to choose when auditory over-stimulation would normally trigger acting out or negative behavior. In short, the music experiences were sensory awareness resources for interrupting neurologic noise set up by the environment. The results from this small study were mixed. Two of the three patients used the music based strategies and demonstrated reasonable success over the eight week program. One patient demonstrated no recognizable positive change in behaviors. The study, however, raised a number of interesting questions. Mostly it inspired thinking about what different approaches or techniques might be designed in order to practically expand music interventions to the entire unit.

The census of this unit, at any given time was 12-18 coed patients with a range of ages 3-12. The therapeutic music activities/experiences available to all patients, at that time, included two active music making groups and a small group or 1:1 music and imagery session. Most patients were available for the active music groups but not necessarily on a consistent basis. Particular children were selected for small group or individual sessions through clinician recommendation. "Lullaby Night" replaced the small group/individual time in the summer of 2000. This was an evening music time that was a passive music experience and all patients participated simply by being on the unit.

Initially the time frame for lullabies was from 19:00 to 20:30 PM. The music was performed using solo female voice and acoustic guitar accompaniment. The purpose was to provide calming but organized sounds on the unit to help the children settle more easily into bedtime. As the months went by, Tuesday became the established lullaby night. The time was moved to 18:30-20:00 since more activity occurred at 18:30 and the hope was that anxious behaviors might not escalate if the music started before such things as the end of visiting hours, snack and ADLs (activities of daily living). A review of the Aggressive Behavior Log from 1 March through 31 December 2001, provided insight that the 90 minutes of music on lullaby night indeed might have an impact on patient bedtime behavior and even affect the overall nighttime aggression levels. Data was examined for entries between the 18:30 and 06:30 hours. Log documentation showed 18 entries for Tuesday evenings

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Patient responses to hospital sounds

as low compared to a high of 51 on Fridays over the nine-month period. Seeing these figures was startling and the question was "Could it be the music?" (insert charts c & d )

If the music was helpful in reducing the number of aggressive behaviors on Tuesdays maybe music would also be useful on other nights. Providing live music seven nights a week was not possible but recorded music was used regularly on the unit for a number of activities but not with the same intentions with which the lullaby night was designed. The next step then was to design an appropriate recorded music program for the same time frame (90 minutes) and the same placement (provided on both corridors) and collect the number of aggressive behaviors logged for the same twelve hours (18:30-06:30). This was the called the 90 minute Music Study. This use of music as a passive intervention for reducing milieu disruptions related to patient bedtime anxiety on the childrenﾃ不 unit was run for a six week period. Data was also collected for 2 weeks pre and 2 weeks post project. The study was conducted from mid April through June of 2002. Three music styles were used as two-week interventions, all of them recorded on compact discs. Music styles were selected based on the types used most often on the unit for "quieting/calming" effect.

The first style was electronically generated "ambient" music. The second style was instrumental classical music. The third style was the same vocal music with guitar accompaniment used on the lullaby night but professionally recorded on to compact disc for use in the study. A maximum of five battery-supplied boomboxes were strategically placed in corridors and monitored for consistency in broadcasting. The six weeks of the recorded music intervention was designed to use the 18:30-20:00 time frame for six nights and Tuesday remained the "traditional live music lullaby night. The following information was provided at the end of the 10 weeks: (insert charts e & f side by side)

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Sound Environment Responses The impact of the three interventions on patient behavior was not found to be statistically significant, however, the music used in intervention number two appears to have had a positive effect. What again appeared obvious was that classical recorded music had some beneficial impact on decreasing patient anxiety and aggressive behavior around bedtime activity. Short clips of each style of recorded music were then examined and a great discrepancy in frequency wave shapes was obvious. (insert charts g, h, i) The Aggressive Behavior Log documented that behaviors were more or less aggressive during the various styles of music. Looking at the wave shapes of these styles might provide a sense of why documented behaviors were so different. Describing the three music styles via wave shapes and suggesting how documented behavioral responses might be explained was important. The synthesis of both pieces provided four considerations: (1) the type of rhythmncity, found within the melodic and harmonic structure of classical music, provided an entrainment and an unconscious sense of predictability; (2) nature sounds, or electronic unmetered music could not provide the necessary sense of beat for the entrainment useful to feed and calm an anxious auditory system; (3) scanning for low frequencies is a significant responsibility of the dorsal component of the vagal system for survival, thus, in the most alert of states, auditory filtering goes on for survival's sake; and (4) The frequency organization of the classical music selected for the study may have absorbed intrusive low-frequencies of the ambient environment, in a sense transforming them.

Challenges to providing sound transformations Fundamental to the delivery of recorded music in this study were both the design and construction of the unit and the music delivery system itself. The construction of any public or commercial structure obviously has specific limitations especially in terms of materials used in its construction, due to codes and regulations dictated by the purpose of the facility although the actual configuration might be negotiable.

The design of this particular unit was a sort of double "L" shape with one short and one long corridor (all carpeted) on to which patient double rooms open. The routing of sound down both corridors and into rooms was one challenge. There was also the fact that not all patients sleep in their assigned rooms, especially when they are new admissions who must sleep within staff sight. Such patients then are bedded in either of two spaces near the nurses' station in rooms designated for dining and

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Challenges to providing sound transformations

lounging spaces. Sound delivery then becomes more challenging, given the sound of electrical appliances such as refrigerators, fans and clocks or proximity to phones and overhead speakers.

Five boomboxes were chosen for the sound delivery with three being the same brand and style for the corridors (2 on the long and one on the short) and the other two boxes reserved for the dining and lounge areas. No power cords could be used for operation so all devices were battery powered. Since fire codes require that corridors remain obstacle free at all times, there are no shelves on which to place objects of any sort, therefore, the boomboxes were placed on the floor in the corridors and on shelf space in the dining and parlor areas. An additional piece of design that challenged sound routing was a crown section at the start of the long corridor.

The difference in ceiling materials and in the increased height created a type of "capture" space for sound. (insert chart j) The greatest challenge in music delivery, however, was due to the styles of music.

The electronically generated "ambient/new age" recording had no pulse and could be started even at random without sounding "out-of-sync". The classical recording demonstrated that even though with a synchronized start, the speed at which each boombox played was just enough different that after three to four minutes of music, each one was out of phase with the others. But because the classical music was instrumental/orchestral with varying frequencies and implied pulse, careful monitoring of volume limited the impact of the phasing problem to a great degree. The recorded "lullaby" disc provided the greatest dilemma related to phasing. Having a highly defined pulse from the guitar accompaniment and the vocals being word based, the issue of "out-of sync" was huge. Constant monitoring of volume and cutting back to one boombox on each corridor helped only minimally. Words/lyrics travel easier in terms of consciousness and if those words are not together the sound can be irritating. So there were routing issues due to unit design and the material of the built environment, and the sound delivery system added its own dilemmas. It isn't surprising then, that no significant differences were found among the treatments, except that the classical music still appeared to provide some positive effect.

Keeping in mind that the Tuesday's lullabies remained a constant but were "live" versus recorded music, the Tuesday data was also collected but not figured into the six nights a week when recordings were used. Examination of this data showed that across the three interventions produced the same number of documented incidents as the classical music two-week intervention. So another question popped up, "What else is at work?" Often the simple or obvious answers are the most profound.

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The answer seemed to be "Because of particular differences between live and recorded music. More precisely: live music has an impact upon the ear different than recorded music by the sheer fact that the environment both acoustically and interactionally are “in process”. In addition, frequencies and decibels are in that process “in time” – one element that recorded music freezes then replays “out of time”. Therefore, the interaction between performer and audience is organic and dependent upon the: (1) sound dissemination system; (2) acoustics of the environments; (3) auditory perceptions; and (4) "in-the-moment" responses.

Sound Hospital Responses Returning, once again to comments from Mazer's work: "To be a state-of-the-arthospital, the auditory environment must exemplify the highest and most compassionate standards of patient care. Setting sound standards for equipment, technology, and design makes it possible for a patient to move through the healthcare system, from department to department, and experience the same standards of care.

Aim for more than auditory neutrality of the myth of “do no harm” when it comes to noise and distraction by providing music and nature, fountains, or other pleasant sound sources that can improve the quality of the healthcare experience. Go back to your own hospital and listen. What you hear should reflect the same values and standards as the clinical care you provide."

The seeming positive effect of live vocal with accompaniment and recorded classical music provided enough curiosity to consider further investigations. The next study was designed to examine the impact of live classical instrumental music and live vocal music on the bedtime milieu behaviors. It was completed in March of 2003. This also provided exciting information and the most recent study was designed to examine the impact of recorded classical music on targeted nights. It was completed May of 2004. The results of both studies are to be published at a later date.

Over stimulation of the human auditory system can negatively impact treatment in health care settings. For most people, the effect of auditory stimulation is an unconscious experience. The auditory system is the only sensory system over which the individual has no control. It is the auditory system, however, that is most assaulted yet may have the greatest capacity to mediate and repair much damage to both behavior and physiology. As awareness becomes conscious related to the impact of both general and particular auditory stimulation on behavior, such sounds may then

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REFERENCES

become a significant consideration in the design of facilities offering health related activities as well as a tool for treatment.

REFERENCES Chitty, J. (2002) Polyvagal Theory, the Triune Autonomic Nervous System, and Therapeutic Applications. www.energyschool.com.

Mazer, S. (2002), Health Facilities Magazine. May. www.hfmmagazine.com Porges, S.W. and Bazhenova, O.V. (1998). Evolution and the autonomic nervous system: A neurobiological model of socio-emotional and communication disorders.

Internet document www.saveachild.com/porges.hmtl.

Wesley, S. (2001). Within these walls: Auditory considerations in a psychiatric hospital for inpatient children. Proceedings: Integrating Design and Care in Hospital Planning for the New Millennium. Karolinska Institute.

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Music Therapy Today, Vol. VI, Issue 4, (November 2005) a publication from MusicTherapyWorld.net

CHAPTER 62

Dialogues about music therapy research

Wheeler, Barbara L. University of Louisville Louisville, KY USA barbara.wheeler@louisville.edu

A number of changes in the status and ways of viewing music therapy research have taken place in the last decade. In this presentation, they were shared from the perspective of the editor of Music Therapy Research: Quantitative and Qualitative Perspectives (1995). In this presentation, the editorâ&#x20AC;&#x2122;s views of changes in the status of music therapy research and their relationship to the plans for a revised edition the book, which will be titled Music Therapy Research, 2nd Edition, were presented. In addition to the editor/presenterâ&#x20AC;&#x2122;s perspectives, dialogues between and with some of the contributers to the book were shared.

Ten years ago, there was only one book specifically on music therapy research, Experimental Research in Music by Clifford Madsen and Charles Madsen (1970).

In the intervening 10 years, a number of books appeared on this subject, including

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the following: Music Therapy Research and Practice in Medicine by David Aldridge (1996); Beginning Research in the Arts Therapies by Gary Ansdell and Mercedes Pavlicivec (2001); Qualitative Music Therapy Research: Beginning Dialogues by Mechtild Langenberg, Kenneth Aigen, and Jörg Frommer (1996); Multiple Perspectives: A Guide to Qualitative Research in Music Therapy by Henk Smeijsters (1997); and Music Therapy Research: Quantitative and Qualitative Perspectives, edited by Barbara Wheeler (1995).

Need for New Edition The need for a new edition was perceived as being due to the following:

• Increases in literature, updated references • More international • Clarify relationship of research methods to ontological and epistemological stances

• • • • • • •

Quantitative-qualitative clarification and discussion Define and clarify qualitative methods Questions about philosophical inquiry and theory development Clarify some issues in quantitative methods More complexity in “other” approaches Case studies—qualitative and quantitative Computer applications

More information on some of these needs is shared below:

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International Focus

International Focus The first edition included only U.S. authors, while the second edition includes 13 international authors. The authors of the second edition, and their countries, are included in Figure 1.

FIGURE 1.

Music Therapy Research, Edition 2

Barbara L. Wheeler, Editor I. MUSIC THERAPY RESEARCH: OVERVIEW AND ISSUES 1. Introduction: Overview of Music Therapy Research - Barbara L. Wheeler 2. A History of Music Therapy Research - Jane Edwards 3. Philosophy and Theories of Science - Even Ruud 4. Principles of Quantitative Research - Carol Prickett 5. Principles of Qualitative Research - Barbara L. Wheeler & Carolyn Kenny 6. Funding Music Therapy Research - Jane Edwards & Debra Burns II. THE RESEARCH PROCESS 7.Topics and Questions for Music Therapy Research - Kenneth E. Bruscia 8. Developing a Topic - Barbara L. Wheeler 9. Reviewing the Literature - Cheryl Dileo 10. Designing a Quantitative Study - Barbara L. Wheeler 11.Designing a Qualitative Study - Kenneth E. Bruscia 12. Data Analysis in Quantitative Research â&#x20AC;&#x201C; Statistical Methods - Tony Decuir 13. Computer Programs for Quantitative Data Analysis - Tony Meadows

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14. Data Analysis in Qualitative Research - Kenneth E. Bruscia 15. Computer Programs for Qualitative Data Analysis - Jim Musumeci, Joseph Fidelibus, & Suzanne Nowikas-Sorel 16. Writing the Quantitative Research Report - Michael G. McGuire 17. Writing the Qualitative Research Report - Kenneth Aigen 18. Ethical Precautions - Cheryl Dileo 19.Evaluating Quantitative Music Therapy Research - Cathy McKinney 20. Evaluating Qualitative Music Therapy Research - Brian Abrams III. TYPES OF QUANTITATIVE RESEARCH 21. Experimental Research - Suzanne B. Hanser & Barbara L. Wheeler 22. Survey Research - Tony Wigram 23. Meta Analysis - Cheryl Dileo & Joke Bradt 24.Single Subject Designs - Quantitative Case Studies - Henk Smeijsters 25. Single Subject Designs - Applied Behavior Analysis - Suzanne B. Hanser IV. TYPES OF QUALITATIVE RESEARCH 26. Phenomenological Inquiry - Michele Forinash & Denise Grocke 27. Hermeneutic Inquiry - Mechtild Jahn-Langenberg & Joanne Loewy 28.Naturalistic Research - Kenneth Aigen 29.Grounded Theory - Dorit Amir 30. Heuristic Inquiry - Kenneth E. Bruscia 31.Ethnographic Research - Brynjulf Stige

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Research Interests, Methods, and Epistemologies

32.Participatory Action Research - Brynjulf Stige 33. Narrative Inquiry - Carolyn Kenny 34. Morphological Research - Eckhard Weymann & Rosemarie Tüpker 35. Qualitative Case Studies – Henk Smeijsters & Trygve Aasgaard 36. Arts Based Research - Diane Austin & Michele Forinash 37. Personal Construct Analysis - Brian Abrams & Tony Meadows V.MUSICAL, PHILOSOPHICAL, THEORETICAL, & HISTORICAL RESEARCH 38. Approaches to Researching Music - Lars Ole Bonde 39. Philosophical Inquiry - Kenneth Aigen 40. Developing Theory - Kenneth E. Bruscia

41. Historical Research - Alan L. Solomon

Research Interests, Methods, and Epistemologies It is expected that the new edition will help readers to understand the importance of coherence among interests, methods, and epistemologies. There is ongoing discussion of this in many chapters of the book. In addition, the new edition includes a chapter on Philosophy and Theories of Science which addresses these issues.

QUANTITATIVE – QUALITATIVE ISSUES

There are various attitudes1 toward this issue:

1. These labels, except for mixed methods, are from Bruscia (personal communication, 2003, revised 2004). Some of this information was revised after the presentation in Finland.

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• Radical quantitative – People holding this view use only quantitative methods and believe that only these methods produce useful information.

• Assimilative quantitative – People holding this view do quantitative research

but supplement it with qualitative information. A typical study using this approach might use information acquired by interviewing people after a quantitative study to help to understand why they responded as they did. The presenter suggested that these researchers use qualitative data but that this would not qualify as a qualitative study.

• Equal acceptance – mixed methods designs – Mixed methods designs attempt to

utilize both quantitative and qualitative methods, and are a popular approach at this time. Equal acceptance can also mean that the two paradigms are not mixed in the same study (a stance that Bruscia took some time ago). Thus, equal acceptance must also include the use of quantitative research for those questions requiring positivistic answers and the use of qualitative research for those requiring nonpositivistic answers.

• Radical qualitative – People holding a radical qualitative view believe that only qualitative methods are suitable for doing music therapy research, and reject any use of quantitative methods.

• Assimilative qualitative – People holding this view do qualitative research supplemented or informed by quantitative information. An example is the Rep-Grid technique.

DEFINE AND CLARIFY QUALITATIVE METHODS

The first edition of the book included only two types of qualitative methods, with the following chapters:

• Interpretational Research • Phenomenological Inquiry The second edition includes the following chapters on qualitative methods, clearly offering much more coverage of these methods:

• • • • • •

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Phenomenological Research Hermeneutic Inquiry Naturalistic Research Grounded Theory First-Person Research Ethnographic Research

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Research Interests, Methods, and Epistemologies

• • • • • •

Participatory Action Research Narrative Inquiry Morphological Research Qualitative Case Studies Arts Based Research Personal Construct Analysis

CLARIFY ISSUES IN QUANTITATIVE METHODS

The quantitative section of the first edition of the book was organized as follows:

• • • • • • •

Experimental Research Descriptive Research Survey Research Ex Post Facto Research Case Studies Developmental Studies Applied Behavior Analysis

The second edition has the following organization:

• • • •

Experimental Research Survey Research Quantitative Case Studies Single Subject Design - Applied Behavior Analysis

The methods contained in the Descriptive Research chapter in the first book have been moved to other chapters in the second edition, with Survey Research, which is often done in music therapy, having its own chapter. Ex post facto research, which was included under Descriptive Research in the first book, will be covered under Experimental Research in the second edition. The second edition has a chapter devoted to Quantitative Case Studies, as well as the chapter on Single Subject Designs/Applied Behavior Analysis (which could be included with case studies).

Longitudinal studies, a type of descriptive research, will be included in a portion of the Quantitative Research section, as this type of research could be very useful in music therapy even though there is little of it at this time.

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COMPLEXITY IN “OTHER” APPROACHES

The first edition of the book included Philosophical Inquiry and Historical Research as other approaches. The second edition includes four in this section, reflecting additional thought and discrimination among some of these approaches to research. These chapters are Approaches to Researching Music, Philosophical Inquiry, Developing Theory, and Historical Research.

Case Studies This edition includes description and examples of case studies in two categories, Qualitative Case Studies and Quantitative Case Studies.

DISTINCTIONS AND DISCUSSIONS

Four areas were considered under this topic: the discussion of qualitative and quantitative distinctions, which continues; research, theory, and practice is an area in which the distinctions are changing; a discussion of what is research and when something becomes research; and discussion of qualitative philosophies, methods, and techniques. These are considered in more detail below: Qualitative – Quantitative Distinctions. This discussion is based on the different assumptions underlying positivist and nonpositivist approaches to research. Dialogues with Jane Edwards and Kenneth Bruscia, quoted below, were shared: Jane Edwards, Sept. 15, 2002, wrote (in an e-mail to the presenter2): I would suggest that positivist research is really not done in music therapy any more. It is the paradigm that requires all variables to be controlled in the method so cannot be conducted in a natural setting – since nearly all MT research is conducted in the natural setting I suggest it is post-positivist or constructivist in orien-

2. In a follow-up e-mail, following the conference presentation, Jane Edwards has clarified and said: I mean that post-positivist means everything after positivism and true positivistic research can only use the laboratory (because in the natural setting even if our variables are as controlled as they can be there are confounders—in post-positivism the belief is that the natural setting generalises best to the natural setting and hence the natural setting is used rather than the lab). Because of this I believe that the current crop of quantitative research in music therapy is post-positivist and that because post-positivist means (simplistically) everything after positivism then constructivist approaches can also be described under a meta-category of post-positivism.

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Case Studies

tation. Post-positivist uses the natural setting but if quantitative method then has a control and if qualitative method then usually has a quite structured method (like GT but sometimes case study fits here) and then constructivist research is where there is no possibility to use quantitative method because the ontology doesn’t allow it – the belief is that reality is constructed and therefore truth is relative.

The Presenter’s View Although music therapy research may not be able to be controlled as completely as Jane feels it should be to be in the positivist paradigm, I think that it is still in that paradigm since it strives to be that controlled and the beliefs underlying it are the same. It makes more sense to me to place many qualitative methods in the postpositivist paradigm.

Ken Bruscia, April 10, 2003 I believe that in qualitative research (practice) there are many paradigms. In fact, that’s the main problem with defining qualitative research or calling it anything else. Based on the Handbook of Qualitative Methods, qualitative paradigms include: postpositivsm, constuctivism, and critical theory. I myself am beginning to wonder whether there are even more, especially if you look at the practices. For examples: When you really get into ethnography, it qualifies as a paradigm – it has its own set of beliefs about the world and knowledge, along with very specific approaches to research; the same can be said for hermeneutics…. Maybe what I am saying is that a research paradigm can be broadly defined as a “way to knowing what is of interest.”

It is the presenter’s view that qualitative and quantitative research are not in opposition but have different sets of assumptions. On question is, can you combine or does this weaken both types? A distinction can also be made between qualitative data, as is often used by people to supplement a quantitative study, and qualitative research, which involves beliefs and methodology unique to this type of research.

DISTINCTIONS AMONG RESEARCH, THEORY, AND PRACTICE

These seemed distinct in first edition but, particularly with participatory action research, the distinctions are now blurred.

Dialogue with Bruscia, April 9, 2003, in which he said: “The distinctions between research, theory, and practice are arguable, and possibly irrelevant, because qualitative researchers are really blurring the boundaries….

Nowadays, any way to knowing can be considered research. Also, nearly every effort to do one is influenced by the other in varying degrees.”

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WHAT IS RESEARCH? WHEN DOES SOMETHING BECOME RESEARCH?

This question comes up often in both quantitative and qualitative research. A dialogue with Carolyn Kenny, shared through her contribution of the chapter on Narrative Inquiry as part of the qualitative research section, included: “Though much scholarly work is involved in the creation of categories, we must take some caution regarding the assumption that research must do an analysis and create categories to qualify as research.”

In quantitative research, people often collect data but this is not necessarily research.

Finally, as discussed earlier, people may collect qualitative data. This may be done when the researcher, as follow-up in a quantitative research study, interviews participants to find out their perceptions of the research. This would be qualitative data but not qualitative research.

QUALITATIVE PHILOSOPHIES, METHODS, TECHNIQUES

A number of distinctions and clarifications as applied to qualitative research come up in the process of working on this edition of the book, and will appear in the book itself. One area is exemplified in a discussion among Barbara Wheeler, Kenneth Aigen, and Kenneth Bruscia. The dialogue is summarized below: Aigen wrote, “Just about every single qualitative study in music therapy uses elements of different approaches and almost none of them follows one method exclusively.”

Bruscia wrote, “There are three horrendous difficulties in understanding qualitative research: (1) the different views on epistemology and methodology with regard to the SAME type of research (e.g., hermeneutics), given by different disciplines (e.g., hermeneutics in history is different from hermeneutics in social work,” …

(2) the overlaps of methodology (e.g., phenomenology and hermeneutics, ethnography and phenomenology). So part of the problem is that when you label your discussion, you can’t keep any boundaries on it… I start on phenomenology and end up on hermeneutics, which takes me to ethnography,” …

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References

(3) Sloppiness with language. People label their research incorrectly, or based on an inadequate understanding.â&#x20AC;?

The dialogue continues in music therapy research continues. These are important issues for music therapy researchers to sort out, and the dialogue is healthy. The presentation ended with an invitation to those in attendance (and others) to join it.

References Aldridge, D. (1996). Music Therapy Research and Practice in Medicine. London: Jessica Kingsley.

Ansdell, G., & Pavlicivec, M. (2001). Beginning Research in the Arts Therapies.

London: Jessica Kingsley.

Langenberg, M., Aigen, K., & Frommer, J. (1996). Qualitative Music Therapy Research: Beginning Dialogues. Gilsum, NH: Barcelona Publishers.

Madsen, C., & Madsen, C. (1970). Experimental Research in Music. Raleigh, NC: Contemporary Publishers.

Smeijsters, H. (1997). Multiple Perspectives: A Guide to Qualitative Research in Music Therapy. Gilsum, NH: Barcelona Publishers.

Wheeler, B. L. (Ed.). (1995) Music Therapy Research: Quantitative and Qualitative Perspectives. Gilsum, NH: Barcelona Publishers.

Wheeler, B. L. (Ed.). (in preparation). Music Therapy Research, Edition 2 Music Therapy Research, Edition 2. Gilsum, NH: Barcelona Publishers.

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Music Therapy Today, Vol. VI, Issue 4, (November 2005) a publication from MusicTherapyWorld.net

CHAPTER 63

Issues in measuring the effects of music therapy with patients with cardiac problems

Wheeler, Barbara L. Symposium Title: Measurement Strategies in Music Therapy Clinical Practice for General Medical Settings

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This symposium presentation described a music therapy program for patients in cardiac units of a general medical facility. The questions addressed in this presentation follow:

• What are the best means of measuring the effects of music therapy with cardiac patients?

• What are the problems with measurement?

The presenter’s experience using these measurement techniques was primarily as part of a summer music therapy cardiac demonstration program. This was part of a 10-week project at a medical hospital in Louisville, Kentucky. The cardiac units offer three types of care: general cardiac care, surgery and follow-up, and shortterm cardiac rehabilitation. Patients typically enter the hospital and are found to have a cardiac problem, then are sent to the general cardiac unit. Those who are found to need surgery go to the surgery and follow-up unit. They are generally on that unit for only a few days. Some are then transferred to the short-term cardiac rehabilitation unit where they stay for approximately a week. Others go back to the general cardiac unit and are typically discharged in about a week.

Although the presenter works part-time at this hospital on an ongoing basis, this 10week project was set up to demonstrate the viability of music therapy in this setting in addition to offering music therapy services on a more intensive basis than is normally possible at this hospital. A music therapy student performed most of the music therapy, under the supervision of the presenter/music therapist, and worked at the hospital 5 days a week for the duration of the project. This was a clinical project, not formal research.

The measures that have been used in the demonstration program include a visual analog scale assessing pain, anxiety, depression, stress, and relaxation; and physiological measures of heart rate, blood pressure, and respiration rate. The results of the visual analog scale are shown in Figure 1.

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FIGURE 1.

Project

Results of Visual Analogue Scale, Cardiac Demonstration

6 5 4 3 Pretest Posttest

2 1 0

Pain

Anxiety

Depression

Relaxation Stress

A review of literature of the results of physiological measures that have been utilized to measure the effects of music and music therapy in cardiac care shows contradictory findings. Some studies find systematic and often positive effects with music, others do not. Explanations for some of the contradictory findings may be lack of clarity in defining the variables including patient characteristics, or present-

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Issues in measuring the effects of music therapy with patients with cardiac

ing accurate information about the music therapy is used, but in other cases, the variation in results seems to be random. In the demonstration program described, there appeared to be many influences other than music therapy on the measures, including mechanical devices controlling heart rate, medication, stimulation from the session and therapist contact. These measures were eventually dropped for this project.

Questions that arise from the experience with the demonstration program include the following:

• What were the differences in these physiological measures and others that do

find systematic changes? Many studies in the literature find changes in heart rate, blood pressure, and respiration rate with music and music therapy, but many do not. Some music therapy studies find changes in hear rate when improvising (e.g., Neugebauer & Aldridge, 1998).

• What distinguishes studies that find physiological differences with music therapy from those that do not find these effects?

• How detailed must attention be to individual differences?

• What music is used and how specifically must it be detailed?

The following psychological measures that might be useful in measuring changes in cardiac rehabilitation were illustrated:

• • • •

Visual Analog Scale McGill Pain Questionnaire State-Trait Anxiety Scale – Spielberger Profile of Mood States (POMS)

Suggestions for further study include developing a better understanding of physiological measures, determining what psychological measures capture intent of music therapy treatment(s), and examining the relationship of physiological to psychological measures.

References Neugebauer, L., & Aldridge, D. (1998). British Journal of Music Therapy, 12, 4652.

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Author information

Wheeler, B. L. (2003). Final Report, Audubon Hospital Music Therapy Cardiac Demonstration Program, June 10-August 20, 2003. Unpublished report, Louisville, KY: Norton Audubon Hospital.

Author information Barbara L. Wheeler, PhD, MT-BC Professor and Director of Music Therapy University of Louisville Louisville, Kentucky USA Barbara.wheeler@louisville.edu

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Music Therapy Today, Vol. VI, Issue 4, (November 2005) a publication from MusicTherapyWorld.net

CHAPTER 64

One must not pick the flowers of a gardenâ&#x20AC;? - coping in the shadow of terror

Wiess, Chava Over the past three and a half years I have been treating children who are victims of terrorist attacks and I am a part of a staff that have been conducting workshops dealing with stress and crisis through music . The workshops are geared for both adults and youth who live in high risk areas in Israel. Some of the workshops are for victims of terrorist attacks, and some of them are for their families and friends.

In this capacity I have been frequently called in soon after an attack has occurred.

The people's fears can be divided into two areas. One, they are afraid of being shot at while commuting to and from work, and two, they are afraid of terrorists invading their homes. The reactions to this anxiety can vary between locking doors and shutters during the day or just at dark, some donâ&#x20AC;&#x2122;t travel at all at night and stopped working. Some send their children to live with other relatives. Younger children may start to wet the bed, have nightmares and may refuse to stay alone.

The ongoing anxiety and tension is a daily phenomenon and has lasted in Israel for the past three and a half years since the recent terror attacks started.

In the framework of this presentation I would like to focus on the people, their feelings, and the coping mechanisms of both people who live in high risk areas in general and terrorist victims in particular. I will describe the feelings and the strength

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One must not pick the flowers of a garden” - coping in the shadow of terror

that these people gain through music, since music is a very important part of the workshop and helps people grapple with their emotions.

Up To this day about a thousand Israelis have been killed by terrorists. This number, in percentage of the population would be about ten thousand in most European states. This number reflects those killed in the past three and a half years. A large part of the victims are children, and many more children are left orphaned which one or both parents died as a result of a terrorist act. In the places that I work, 125 people have been killed, 50 of which are children and youth.

Workshop Procedure The workshops take place in the workplace or in the places where people live. They last about five hours and occasionally they are divided into a number of sessions.

There is an enormous mount of people that return to the workshops . During the workshops we concentrate on releasing tension, expressing and coping with feelings by listening to Israeli songs, playing musical instruments and songwriting. In this presentation I will focus only on the use of Israeli songs.

ISRAELI SONGS

Israeli songs take a central role in Israel. Communal singing in public is an important and meaningful part of Israeli culture. It raises the national morale and it helps people support each other in difficult times. Singing in public is acceptable in almost all parts of Israeli society and it helps to unify and to soothe everyone. The history of Israel enfolds through the songs, including the meaningful events and the difficult times. During the past few years there has been a strengthening of this phenomenon due to everyone’s need for a boost to their morale and a feeling of belonging. That is why I decided to work with Israeli songs in my workshops.

HOW THIS TAKES PLACE

The songs are selected according to the age and type of population, for example the youth, choose songs from the last decade, or adults will choose older songs. Every member gets a booklet with 50 songs. The group members are invited to choose a song that expresses their ways of coping with a crisis situation. In reality, what happens is that they select songs that express their feelings that arise from the situation. there are those who select songs which express their ways of coping with personal crisis. We perform every selected song with my accompaniment by the guitar, and everyone singing together. The one who chose the song recites the sentences which

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focus his emotions and then we have a discussion among the group members about this person's way of coping with the situation. My role as a group leader is to act as a mirror and to reflect their pain and their strengths. Their song selections seems to be very significant in that it signifies everything that bothers that person. My feeling is that the guitar accompaniment is of great assistance in helping the group members to connect. We are all aware of the difficult times in which we are living but we are not totally aware of the feelings that these times engender. Israeli songs opened a window to me into man’s soul and gave me a chance to penetrate to the world of pain, hope, desperation and love. The songs assisted me in coping with fears and anxieties, loss and pain. If it weren’t for the songs’ some topics would not have even emerged verbally. My guess is that a song can contain everything – threatening emotions and thoughts that would not emerge otherwise and subjects which are taboo.

THE IMPORTANCE OF PERFORMING A SONG

Performing a song in a group carries a lot of emotional value. In the literature of music therapy singing songs is an immediate and positive emotional experience.

Combining emotional, verbal, social, spiritual, communicative, physical and cognitive aspects. This experience usually arouses senses of enjoyment, encouragement, belonging, and insight, identifying with the other, cooperation and release from emotional and mental tension. Eliram, who specializes in Israeli songs claims that singing enhances an uplifting of the soul into another sphere. She points out that singing in public is an experience which enhances togetherness and belonging.

This takes place under the impact of the musical and extra-musical components.

When people sing together it is like a person getting in touch with himself. The combination of all of these elements enhances the power of the songs and entails and triggers a direct and immediate reaction of the people who take part in the workshop. The reaction can be physiological such as weeping or laughing and the urge to hug as well as an emotional attachment.

I want to start with the first example. The songs are translated into English, but you will hear the original songs in Hebrew. In most of the examples I will bring only part of the song.

The following song is called “place for Concern” . It was written during the late 70s. It is written in a minor key and is in a melancholy tone. the song speaks about a remote and neglected place that even god is worried about .

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FIGURE 1.

(1st recording+slide)

THE BEAUTY IN EACH SONG

The beauty in the song “Place for concern” is that different people can see different things in the same song, and they can connect to different ideas and feelings. Each person can identify with the verbal or musical content which brings up things from their inner world. We have seen that Yael refused to accept the fact that her flower was picked. Rina, a second generation member of a settlement, chose different words from the same song. “There’s a far-away place, A tiny, miserable, crazy place, A place of big concern". Rina said: “I feel unwanted because of the place where I live. My home is treated like a remote and a neglected place because of what is happening. It is not as simple as they think to leave the house where I have lived all of my life. I feel unwanted and hurt.” Besides the pain Rina feels rejected.

Shelley was calmed by the very same song. She chose a different sentence, the one that talks about G-d sitting there and guarding everything that he created and is terribly worried. Shelley found solace in the sentence “God is worried.” Tova, on the other hand was bothered by the song. It emphasized her deep worry and concern and feeling of helplessness. She is worried about her children and friends and the entire situation in Israel. One can see that the feelings and emotions which emerged from the song varied from pain to anger , sadness to hope and finally to worry and concern. Each one of the participants connected to a certain sentence through the experiences and emotions which emerged from her own personality.

The group provided different outlets for the participants. There were those who were supported by the group which gave them the strength to continue. There were

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others to whom the group provided a place to weep and still others who could raise the questions that they were bothered by. There were those who just needed a place where they could ventilate everything that bothered them.

I will bring some examples where we'll see in some songs people who express their pain and in others find strengthens David chose the song “A ballad to a policeman” FIGURE 2.

(2nd slide).

The song was written in the seventies. It is a song which speaks about loneliness.

The song is melancholic and played in a minor key (2nd song). The whole group sang together and David chose the following sentences from the song. “Deserted are the streets, the alleys are all his, alone again, is he, he and his shadow.” David looked at the group and said: “In the place where I live all the neighbors around me have left because of numerous terrorist attacks. My wife and I are the only ones remained on the street and I feel lonely. I wish I could turn the clock back.” The entire group started to cry in empathy. Towards the end of the workshop David asked to sing “The song of love”

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FIGURE 3.

(3rd slide).

This is a new song which was written 4 years ago. It has a mixed style with an ethnic tone that comes from several places in the world. This style has become very popular in recent years. The song is sung in a major key and its rhythm is lively. It speaks about the power of togetherness (3rd song). David said that the power of togetherness is what gives him the energy to go on in spite of everything. He took a Darbooka and started drumming while the rest of the group started dancing and hugging each other. David found in the songs a way to express his pain and in another song he found strength.

In another workshop, Shosh whose best friend Roni lost her husband during the same month, chose a song called “All the stars” .

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Workshop Procedure

FIGURE 4.

This song was written 3 years ago. The song deals with the attraction that a man has for a woman and his inability to make their relationship real which leads to feelings of pain and powerlessness. The song is played in a minor key and has a large range (4th song). She chose a refrain which described how she felt. When she recited the refrain, her body language was very drawn in and bent over. With a quiet and slow voice full of pain. she recited “all the stars are falling , the brave men are departing.

Whoever shouted is silent, whoever laughed is crying.” Then she said, “ I feel that only by my expressing and touching my pain then I could rebuild myself.” Roni, who had lost her husband just a few weeks previously, was sitting close to her. She couldn’t bear the pain and she started crying. Shosh talked about herself but also transmitted to Roni the message that she couldn’t bear the pain. Until this day, a year and a half later, Roni is still unable to touch and connect to her pain. This affects her functioning at all levels, especially at home. During the same workshop it was very hard for the group to deal with what was happening and they asked to sing the song Amen.

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FIGURE 5.

(5th slide)

This song was written during the nineties in a major key, and has a wide range. The song is like a prayer to G-d asking for strength and protection (5th song). Almost all the member of the group started crying while singing. After they finished singing they expressed the will and the need to strengthen themselves by the following words of the song “strengthen our spirit, give us life and protect us, fulfill our love”.

In these examples, and there were many like this, one can see that the pain can be tapped and a dialogue can be created, where there is a personal interaction between the people and the songs. There is an expression of pain in one song and the need to strengthen in another. In many additional cases the participants “dedicated” songs one to the other in order to encourage and help each other. Occasionally I saw people who didn’t know how to react when someone burst out crying, but they found the way to encourage him by “giving” a song to the person who was crying, which to my mind was like giving a hug.

There is an interesting process here. At the start of all of the terrorist activity you could see that those who lived in high risk areas, where there were a lot of teror incidents and a lot of injuries and loses, people chose songs which spoke about strength, faith, and courage. There was no readiness to deal with pain. My guess was that the fear of dealing with the pain derived from another fear that if they did deal with pain something would collapse internally and their belief would crumble.

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Today the need to deal with pain is legitimate. Also, asking questions and being confused is acceptable, which was not the case in at the start of events. A dialogue that would not be accepted, and emotions that people would be ashamed to bring up can be dealt with through the songs. The barriers come down and the most difficult feelings are tolerated which would otherwise not be accepted. At the same time there is a great mutual support. For example Noam told the group that she chose the song “Solace” which was written in the seventies.

FIGURE 6.

(6th slide).

Composed in a minor key it deals with the need for strength, solace and mercy (6th song). She chose the following sentence from the song: “keeps asking where from, he can draw his strength?” Noam added that sometimes she is ashamed to admit that she has no more strength and she can’t go on: “Everybody expects me to be strong and clear about my beliefs but I have doubts”. She added: “I have always believed in my way of life. I still believe, but now I let myself have questions and doubts.” There was an embarrassed silence in the group, but no one dared to criticize her.

In another workshop Ayala, who had lost her brother-in-law and her two nephews in a terrorist act, chose the song “that’s more than we can ask for” .

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FIGURE 7.

(7th slide).

In this song there is a plea for the trivial things of life and the pain when they are not given. The song is sung in a minor key (7th song). Ayala considered this song a protest against G-d. "My eyes have no more tears”. You have already hit us, after we had already pleaded and prayed. What have we asked for? Only for rain, flowers in the spring, that each of us come home safely? We haven’t asked for anything special! But even these things are not granted to us. The subject of anger towards G-d came up in this song and was followed by a discussion about whether there is room for this type of anger. This topic has been coming up lately and is considered legitimate even in the religious community.

Ways of coping The importance of working in a group is that there are many different ways of coping, and even those who find it very hard and refuse to cope are affected positively by how others think and share their optimism. I will show a few examples of different ways of coping.

Miriam selected the song “Become my friend, become my brother”.

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Ways of coping

FIGURE 8.

(8th slide)

This song was written in the sixties and it expresses the desire for a friend and the quest for help from that friend (8th song). Miriam chose “give me your hand when I call you”. Miriam said that during a crisis she needs a friend by her side. David, as we saw, chose the song, “song for love”. Togetherness assists David, and many others to overcome, to be encouraged, and to be supported. There were people who chose songs which speak about the family as their supporter. There were others who chose songs that speak about faith and prayer that help them to cope. Some chose songs that talked about smiles that help them to cope.

At the start of the terrorist attacks people refrained from bringing up their personal problems. Recently, every time I hand out the song booklets the personal problems come up with all of their accompanying feelings. It could be that continuing stress and tension sharpens their personal problems. The last example is of Ayelet who selected the song “Our way” .

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FIGURE 9.

(9th slide)

The song was originally written during the eighties and rewritten in 2001. It is in a minor key and was written by the poet to his wife who was severely ill. Through the song he wants to tell her that he is with her all the way. The song became popular in Israel especially because of the phrase: “our way is not easy.” While singing the song Ayelet burst out into heartbreaking tears.(9th song) At the end of the song Ayelet could hardly read the line: “you won’t be alone I’ll be with you”. She said: My husband and I have gone through a very hard time. My baby daughter was critically ill and after a while she passed away. My husband told me the following words which were very meaningful for me: “You are not alone, I will not leave you alone, I will always be on your side.” While she was crying Ayelet told the group that only her husband encourages her. The group members had not seen Ayelet before this workshop and they didn’t feel that they were able to get up and hug her.

That is why they hugged her through the songs which supported and strengthened her and were more meaningful than a physical hug.

As I have noted already one of my roles in the workshops is to mirror people’s strengths. Many of the participants were unaware of their power. The songs that they chose gave me the proof and also the way to mirror their strength. Some of them stopped during the process and said: “Wow, I never noticed this, but now that you mention it I can see that it is true”. This mirroring gave them a lot of motivation and the power to continue.

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Ways of coping

Changes that I saw through the song from the outset of the events until the present: 1.

2.

3.

4.

5.

6.

7.

8.

I have realized while treating terror victims and by the reports of the workshop participants that due to the following loss and stress involved, their problems have become more extreme. For example one who was typically tense became even more tense to the point of a total inability to function. Introverted people became even more Introverted. Optimistic people became more empowered. .People who live in high risk areas that are under a lot of tension have had their personal problems come out into the open due to the continues stress and tention. concerning the ability to deal with pain I noticed that there is a difference between those who are religious or traditional in their beliefs and those who are not religious in their ability and will to deal with their pain. People who were not religious were more willing to deal with their pain. From the very start of the period of terrorist acts, religious people did not deal with their pain for a very long time. This could derive from their anxiety and fear of diminishing their stamina. Dealing with pain became possible only after recurrent tragedies, and also from the insight that dealing with their pain did not mean that their beliefs would be damaged. My guess from the beginning was that if they expressed despair or fell apart then they would be saying that they have lost their way. But when they started to deal with their pain they realized that this was a healthy situation and that dealing with pain empowers, supports and encourages them.

The mode of coping by many of the religious people was expressed through their beliefs, through prayer and the spirit and also derived from the very strong need for togetherness and socialization.

The mode of coping by the non-religious was expressed by demonstrating patriotism, love of country and their friends. The non-religious participants, from the very start, doubted that the place where they lived was really their place.

Among the religious participants, at the beginning their was no room or legitimacy for doubts whether itâ&#x20AC;&#x2122;s the right place to live. but after a few months those doubts started to emerge.

The farther into the high risk area that people lived and the more injuries sustained there, the harder it was for people to deal with the pain, and they expressed stronger beliefs that their way was right. As I have noted, though, in the last few months this has changed as well.

Youth and children experience post-traumatic symptoms, contrary to expectations on quiet days. The fears and anxieties emerge and physiological phenomena occur such as bedwetting, dysfunction in studies and aggressive behavior.

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One must not pick the flowers of a garden” - coping in the shadow of terror

In summary, the songs gave people a communication channel to express what was in their hearts. The hardships, pain and even taboo subjects were reflected and brought people to insights. The songs contained everything and threatened no-one.

They supported, empowered and encouraged. Each one found a song that touched his heart and felt that it was written for him only. My feeling is that if it weren’t for the songs, all of the subjects that I have brought up in this presentation would not have come to the surface and would not have gotten their appropriate place.

References: Amir, Dorit (1997). Understanding the role of folksongs in Jewish-Israeli culture: Implications for music therapy. The World of Music, 39:1, pp. 111-127.

Eliram, Talila (1995). “Israeli Songs – The creation and significance of popular musical repetoire at the end of the 20th century”. Thesis for M.A. requirement., Department of Musicology, Bar Ilan University.

Eliram, Talila (2001). Vartitle on the musical and social characteristics of "The songs of the land of Israel, Ramat-Gan. Kohut, Heinz (1957)".Observations on the psychological functions of music”: Journal Of The American Psychoanalytic Association,vol 1-4 ,no.5, pp. 389-407.

Kohut, Heinz. & Levarie, S. (1950).”On the enjoyment of listening to music”. Psychoanalytic Quarterly,vol. 19,p.64 Noy, Pinchas (1989).”Why do we enjoy art." Israel Journal of Psychiatry and Related Sciences,vol 26 ,no3, pp.124-137.

Noy, Pinchas (1967).”The psychodynamic meaning of music-part II.” Journal Of Music Therapy,vol 4 no1,pp. 7-23.

Regev, Moti (1990). The Beginning of Rock: Significance, Handling and Structure in the Field of popular Israeli Music. Doctoral dissertation, Dept. of Sociology and Anthropology, Tel Aviv University.

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References:

Weiss, Chava (1999). The Use of Israeli Songs in Music Therapy in Order to Build Intra- and Interpersonal Communication with Two Youth who Suffer from Different Disabilities. MA thesis, Department of Music, Bar Ilan University

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Music Therapy Today, Vol. VI, Issue 4, (November 2005) a publication from MusicTherapyWorld.net

CHAPTER 65

The artistic creativity of stressed and traumatised people - A music therapeutic interpretation of the tale â&#x20AC;&#x153;The Bremen Town Musiciansâ&#x20AC;? in a

joint Polish-German perspective

Szulc, Wita& Wolfram, Ilse

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Introduction We came to the common work after having met last year in the EMTC meeting. Dr. Wita Szulc, Professor of Wroc∏aw University (Poland), also Head of General Education Department, and President of The Polish Association of Arts Therapists “Kajros” and having published many articles, knows a lot about Art Therapy. As to myself, I do know more about Music Therapy in theory and in practice, as I a am an active music therapist since 20 years and do teach and practice it. In the course of the EMTC meeting, we found how important it is also to learn more upon the working conditions of us professionals within Europe and that this knowledge could lead to connecting, networking, teamworking.

Furthermore, we both share the believe in the importance of a growing Europe.

Wita made it possible to come to Bremen one day after the entry of Poland into Europe on 1st of May 2004, and lived with me through the celebration in the city house. There exists a special political and scientific relation between Poland and Bremen. The reconciliation following the sad events of Second World War has proved successful on many levels.

Our topic touches a few reference theories, such as:

• Artistic creativity • Trauma theory • Literature, i.e.science of Folk Tales to which we will therefore refer in an appropriate and adequate way.

THE CONNECTING IDEA

We do not work with the same target group, but we both are convinced from the anthropological principle of the creative potential within human beings, and therefore have chosen the tale “The Bremen Town Musicians” as a connecting idea, because it is:

• a musical tale • because it can be interpreted as a music therapeutic tale, what we will explain • thirdly because it is an internationally - in variations - well known tale FIGURE 1.

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Introduction

Tales of similar content from all over the world - some examples

• • • • • • • • •

The Bremen Town Musicians (Germany) The Choristers of St. Gudule (Flanders) The Robbers and the Farm Animals (Switzerland) The Story of the White Pet (Scotland) The Bull, the Tup, the Cock, and the Steg (England) Jack and His Comrades (Ireland) How Jack Went to Seek His Fortune, version 1 (USA) How Jack Went to Seek His Fortune, version 2 (USA) The Dog, the Cat, the Ass, and the Cock (USA)

Source: Internet www.abney.homestead.com

• because we both like tales and use them in the therapeutic implementation • and lastly, because I, being from Bremen, have a very direct connection with

this tale, whose symbols can be found all over in Bremen and are being used for many purposes. To the citizens of Bremen, they transfer the meaning of freedom, success and security.

We have drawn from the tale a number of analogies to our professional psychotherapeutic field with stressed and traumatised people.

Of course, we do not intend to exclude other analogies or interpretations, which have already been done or will be made. It is certainly thinkable to imagine the four animals, the later Town musicians, as a team of old age beings. Or to conclude from the tale the necessity to demand the changing of the political structures in those countries where the refugees that I work with come from. Or the actions of the four town musicians can be applied to the viewpoint of jobless people, or for pedagogic purposes, or the protection of animals. And so on and so forth. We realized that it is a tale with an enormous power!

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The tale The Brothers Grimm are well known to many of you as collectors from folk tales.

They spent their lifetime searching for tales and stories, and first published this one in the second edition of their book “Kinder- und Hausmärchen” in 1819. Since then, this tale has remained essentially unaltered in the following editions.

Tales have a lot of common features, which helps to understand their philosophical dimension.

FIGURE 2.

typical tales features 1. PLOT FEATURES THREE PARTS

•The start situation a. lack, deficit= someone needs something b: evil acts= someone commits something bad

•The way of the hero or heroes a: test or probe= he or they must master a dangerous situation b: help or advise= from someone or something comes help, or counselling c: magic= the hero is empowered with a magic gift or charming object

•The solution, the answer a: salvation= of the hero or from another person b: marriage= typical for east-european tales c: coronation= typical in most countries d: punishment of the bad person(s) = reward for the good ones; the bad beings have to be punished

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The tale

2. PERSONS AND COUNTRIES

mostly anonymous and of one-dimensionional (how did the clever Jack really look like), the forest (which forest?)

3. SYMBOLISM OF NUMBERS

a: 2 for polarities = good and evil, life and death b: 3 for the roundness, or endings = twice there is bad luck, but the third timethere is achievement c: 7 for positive strength = the seven dwarfs d: 12 = reflects perhaps a religious connection 4. REPETITIONS

very common. As the plot is often very simple, actions are told repeatedly and often with the same words: â&#x20AC;&#x153;Once upon a time ...........â&#x20AC;? ..........and now to the tale itself, which I cannot recite you completely for lack of time, but in its essential parts. ... Once upon a time....Four animals, who have not known each other before, are the heroes. A donkey, a dog, a cat and a rooster. They have lived together with their masters, and have taken their good share in the hard work in the farms: the donkey carrying sacks to the mill, the dog hunting the hares, the cat hunting the mice, and the rooster prophesising the wheather and holding the herd of hens together. They become old and less and less useless, and therefore they shall be killed. First the donkey notices that it was not a good wind that was blowing and ran away, setting forth on the road to Bremen, where he thought he could become a town musician.

On his way, he meets a dog having also run away, and invites him to beat the drums; he himself will play the lute. Then, later, both of them meet the cat making a face like three days of rainy weather for danger of being drowned, and the donkey reacts: after all, you understand music, come with us to Bremen to become a town musician. Later again, the three refugees meet the rooster crying with all his might, because he will have his throat cut the next day, and there is again the remark from the donkey about music:

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After all you have a good voice. Something better than death we’ll find always.

And when we will make music together, it will be something of a special kind.

So the four go off together, but have to stop in a forest, because Bremen is not be reached in one day. The rooster settles on the top of a huge tree and sees a little spark of light not too far away. Hungry and thirsty, as they are, they set forth again and reach a brightly lit robbers house. They discuss what they can do because all the food and warm atmosphere inside attracts them. They make a plan, to stand each on the back of the other and then make their music all together. They do this, and then crash into the house through the windows, which makes the robbers flee fearing a ghost. They finish the leftovers eating as if they would not get nothing more for four weeks, and settle to their individual sleeping places.

After midnight the robbers send one of the group back to check the situation in the house. Now each of the animals uses its individual capacities to fight back: spitting, scratching, biting, blowing, crying. Very frightened, the robber runs back, and from that time forth, the robbers did not dare go back into the house. However the four Bremen Musicians liked it so well there, that they never left it again.

You have undoubtedly noticed how often the relation to music is being made within this story: there are musical instruments, the voice, and the joint music making.

And these hints are being topped by the donkey, who is somehow the leading and initiating animal, and his remark: “We’re are going to Bremen. You can always find something better than death. And when we will make music together, it will be of something of a special kind.

Therefore the key words, which are relevant for music therapy, in the tale are: We will always find something better than death.

We will make music together.

Analogies from typical tale features to refugees

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starting sitation:

• • • • • • •

interruption of a good development by human made violence, leading to lack of essential security, loss of home leading into a situation as a displaced person question of life or death feeling of dispair, sadness, hopelessness feeling of isolation living at the margins of society – hunger, poverty

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Analogy to stressed old people

• needing good advise 2.

Way of the heroes: Must overcome one or many dangerous situations:

• the situation of the escape itself, • the long travel through the world deprived of material ressources (food, house, no family),

• uncertain arrival in unknown countries • fighting for a new and secure place (legal and juridical, application as asylum seeker, recognition or not, deportation or not,

Now, refugees usually have no magic to survive all this.

But, what helps them on their dangerous passage? There is help by friends, by assisting NGO’s or human rights organisations, and, hopefully, remaining strength to survive. They are challenged to defy their miserable destiny only be devellopping the goal of a new shape or a new period of life = restoring of self respect, discovering of ressources 3.

The answer, the solution

• There can be partly or general salvation = through own forces, therapeutic assistance, acceptance of the new situation

• Marriage: seldom, but happens • The evil-doers being punished: more seldom, but thinkable in case of political changes and torturers being brought to justice.

Analogy to stressed old people Our interpretation of the tale describes the similarity also to senior adults who have in their earlier years not been very creatively active, but who do discover their artistic creativity in their senior years. This creativity may be considered as a form of self therapy, as self consolation or as a tool for increase of self esteem.

If we want to help old people and organize very well their leisure time, we ought to have a sensitive staff who is very good prepared to work with old people. This was the reason that I did some research on understanding the fairy tale “The Musicians from Bremen”.

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The participants were 40 students of Pedagogy in Art Therapy Specialization from A. Mickiewicz University in Kalisz city (Poland).

TABLE 1. Answers

to research question

I don’t like sly fellows and cunning They (animals) achieved this place to live through violence and intimidating. I don’t accept these methods These animals don’t make music, only noise I don’t like it (3)

Where is Bremen in the fairy tale – I don’t understand the title of the fairy tale Fairy tale says that we ought to treat animals very well, because many people treat animals badly

Understanding of educative potential

bad fortune of the old people in society: no place in family house they have to go to nursing home (In Polish morals, adult children ought to care of old parents) Transfer to social problems (28)

Robbers house is a metaphor of a nursing home: for many people there life is better thaninthefamilyhouse It is a wonderful mirror of contemporary world: some times rejected people can gather and make a group of friends to became happy and to start believing in themselves.

If we are together we could effectively fight against evil I like the fairy tale because I always take the part of rejected people

Transfer to humanitarian solutions (8)

The fairy tale tells about friendship: thanks to friendship we can achieve more and cope with great difficulties in our life Legende: Results of answers to the research question:Results of answers to the research question: What is your understanding of the tale „The Bremen Town Musicians“?

N = 40 students of Pedagogy with Art Therapy specialization = 38 female, 2 male Location = A. Mickiewicz University in Kalisz city (Poland).

Conclusion: Creativity is the ability that we have in giving new answers to the situations presenting themselves before us. It’s the “antidote” of rigidity, a trend that comes with the aging process, both physically as well as mentally.

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Conclusion:

In the last few years there is a significant change in the profile of the population in Poland as well as in other European countries, a sensitive one that can be observed in numbers as well as in cultural and social changes. The percentage of individuals of age 65 and over, is going to increase. This change in the demographic profile of the population can also be seen in cultural terms.

The “new” old age population has the effect that demands for services in many areas and for different concepts of aging and being old, and how we view the elders segment, are created. Life review will be an important feature of the therapeutic process for this segment. The prophylactic therapies and activities can play a very important role as the interdependence between physical and mental health is widely recognized nowadays.

When we work with elderly people, we work with people from different backgrounds and histories.

We can say that looking for other formal solutions for own work is a metaphor for looking for new patterns of behavior and belief.” Quotation from G. Brioschi: Art as therapy for the elderly.”

To come to the psychological situation of old people in general, I want to refer to Ruth Bright’s observation, that adult children do move away because of business life, but old people feel the lack of company and practical instances of family affection. Isolation is a common phenomenon among our ageing population, and for many it is the cause of deep loneliness and ,perhaps, of consequence, depression.

We see isolation not only in people who are living independently, but also amongst people who are in hospital for rehabilitation and are living in nursing homes.

But social relationships can be developed, enhanced and reestablished with the help of music-based programmes, whether we are looking at old-established familylinks, building new bridges between residents in a hostel or nursing home, or helping to strengthen and re-establish the intimate bonds which have been strained by long illness or prolonged time in hospital.

WORKING WITH THE RESSOURCES OF TRAUMATISED REFUGEES

To come back to traumatised refugees - and almost all refugees are traumatised - , they may find their way within Germany to psychosocial centres, called REFUGIO. I am working on an hourly basis for this institution. The Bremen center is now 15 years in existence, similar associations exist in several cities through the financial help of the communities, churches , UN High commission for refugees and the UN foundation for torture victims. The work is done by a network of interpretors and

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professionals on a social, medical and therapeutic level. The three people I have been working with in the last year have come from former Yugoslavia, Turkey and Sri Lanka. Common to them is, that they suffer from a series of somatic and psychosomatic illnesses, which have to be taken seriously and examined. When we see people with PTSB = Post traumatic stress disorder according to WHO 1994, we know that they have lived through "events of short or long duration bringing with them extreme danger of catastrophic dimension, which could cause deep despair with almost every man". The REFUGIO concept goes beyond the WHO definition, as it differentiates short traumatic events from longlasting and repeated traumata, and as it differentiates between man made disasters, catastrophees and accidents.

Refugees and asylum seekers are generally forced to stay idle because of not being allowed to work. Therefore it is important to try to establish a timely structure with them. And it is important not to remain where they are in their attitude to the world, but to help develop positive ressources. We must insist that there is the lifetime before and after the trauma and not remain at the trauma.

I would like to give an example. My client is a 38 old year old Tamil man from Sri Lanka, who finished school at 17 years with ordinary level and could not go further due to the Singhalese repression towards the Tamil population. He then joined politics, was involved with the Tamil Tigers movement, was betrayed and arrested. He then suffered 6 years of military and police prison, including severe torture. He gave a very unstable impression when I first saw him. His response to the therapeutic setting is very positive: he can make use of the therapeutic relation and possibility for creative musical expression. His favorite instrument is the marimbaphon whose sound he loves for its warmness and clearness. He also has discovered, or better: rediscovered - the joy of singing. He once sang completely free a long song, that turned out to be a fisher men song. Translated into English, the words are about the following: We are born on the land, but we go onto the ocean, we find ourselves in the middle of the ocean and are far away from the land, where my wife and the children are. I remember them, although we are far away and we have no connection. They also think about with sorrow and look out, when I will be back.

On the ocean, there is always the possibility of thunderstorms, then I will be in great danger, and maybe I will perish very fastly without being helped by someone.

Also, if I need to drink water, no one can provide me with water. I am all alone there, far away. I hope that the Gods will protect me, and that they do see me, all alone far away on the ocean.

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Conclusion

His reaction on listening to the music and also to a short taped piece of conversation between us before the song: thats my voice, thats my voice, I have never heard it.

Then he hummed to the song, while getting more and more quiet and sad, and then broke into a spontane sobbing, followed by long crying. Then he said: you know, in Sri Lanka, people never told me how to talk correctly, they always said, oh you, you cannot even talk how it is expected. And now – you talk to me and I feel so respected.

Question: do you like it to hear yourself talk Answer: Oh yes, very much - and then he was shaken by another outbreak of crying, for which he excused himself later.

I concluded the session, saying: next time we continue recording and making music, and he laughed.

The theory of music therapy establishes some goals of intervention, one of which is to contribute to the restoring of identity. Now, this man can get back a part of his broken identity by rediscovering his social roots, expressing his creative singing and therefore integrating the pain of humiliating experiences of the past into the present awareness of himself.

Conclusion In the course of the presentation, we both found how important it is to learn more about the working conditions of us professionals within Europe. This knowledge, however, is the base to build our music therapeutic profession and can lead to connecting, teamworking, and networking.

Literature Brioschi, G (2001). Art as therapy for the elderly.” In Arts-Therapies-Communication. On the way to a Communicative European Arts Therapy. Vol.1 (379 –388).

LitVerlag Münster

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Gebrüder Grimm (1819). Erstausgabe der Kinder- und Hausmärchen. Hier: 1937, Knaur

Author information Szulc, Prof. Wita PhD, Wroclaw University 061 – 064 Poznan PL - Folwarczna 21/44 wszulc@amu.edu.pl www.kajros.pl wszulc@amu.edu.pl, wszulc@pedagogika.uni.wroc.pl Ilse Wolfram, Diplom Psychologin, Music therapist, Stader Str. 31 D - 28205 Bremen Ilse.wolfram@t-online.de

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Music Therapy Today, Vol. VI, Issue 4, (November 2005) a publication from MusicTherapyWorld.net

CHAPTER 66

Alex – An ongoing research on alexithymia and regulative music therapy

Wosch, Thomas In psychotherapy, after the emphasis on bonding theory of the recent years, the preoccupation with alexithymia has become the most important topic in the field of psychotherapy and psychosomatics. Issue no. 2/2004 of Psychotherapy and Psychosomatics is dedicated solely to alexithymia. This disorder already forms a very large area of research. Graeme J. Taylor, one of the most renowned specialists in the subject, underlined this fact in the lead article of the issue by pointing out that in PsychINFO we can currently find over 1000 articles about alexithymia. As is to be expected, several measuring methods for alexithymia, as well as therapeutic approaches, are discussed in the following articles of this issue of Psychotherapy and Psychosomatics, but not a single word is said in this context about music therapy. Nevertheless, music therapy in particular can offer a very special contribution to therapeutic approaches for treating alexithymia, which will be the focus of my paper. I will show this by the example of first preliminary results of a study about alexithymia and receptive music therapy. In the following I will briefly talk about the disorder of alexithymia: afterwards I will introduce the design of the study and its preliminary results.

Alexithymia is a term for a disorder from clinical psychology, which was named and discussed first by P.E. Sifneos in 1973. Contemporary understanding defines alexithymia as follows: “… alexithymia involves a deficit in symbolisation in

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which the somatic sensations associated with the states of emotional arousal are not strongly linked with images and words.” (Taylor & Bagby 2004, 70) The original meaning of an inability to name emotions (a-lexi-thymia) is here differentiated by the lack of symbolisation of emotions and their physical expression (emotion, the status of body and soul, Ulich 1992) through language and associations. This deficit in symbolisation will play an important role further on for the disorder-specific choice of corresponding music therapeutic approaches. But it becomes clear already in the definition of alexithymia that especially music therapy can be the means of choice with its very specific presymbolic opportunities. Alexithymia in itself is not a disorder that can be found in diagnostics like ICD 10 or DSM IV. Rather it is a very complex symptom, which appears primarily with somatoform disorders, however it is also discussed in connection with affective disorders, obsessive-compulsive disorders, abuse and today even commonly in personality and social psychology. A recent Finnish study even came to the conclusion “that alexithymia might be related negatively to survival and longevity.” (Taylor & Bagby 2004, 75; Kauhanen e.a. 1996). This means that alexithymia forms on the one hand a specific part within various disorders as a symptom as well as a spreading concept of explanation for psychological disorders. Further differentiations for alexithymia name a psychological processing of emotions that is disturbed by the disturbed perception and verbalisation of emotions (Kupfer e.a. 2001, 5). This goes especially for the externally oriented style of thinking – the pensée opérationaire (Marty & de M’Uzan 1978) – of alexithymia. With this is described that in problematic situations the possibility for analytical thinking is not given, i.e. no reflection about solutions can be observed. It is very interesting that this is described as a problem of adaptation demand in the sense of cognitive learning theory (Kupfer e.a.

2001, 16) even though alexithymia originated from a psychoanalytical background.

This implies in the sense of the most modern psychotherapy a further comprehensive, here approach-comprehensive character of the alexithymia concept for the subject of psychotherapeutic approaches for psychological disorders. In total we can name three components that characterise alexithymia as a phenomenon: a) disorders in the identification of emotions, b) disorders in describing emotions, and c) the already named externally oriented style of thinking (Kupfer e.a. 2001, 15-16).

In the issue of Psychotherapy and Psychosomatics that was already named above, especially the Toronto alexithymia scale is emphasised for measuring alexithymia in several articles and even in the named lead article by Taylor (TAS 20 / TAS 26).

With 20 self-assessing questions in English and 26 in German, the three aforementioned items of alexithymia are imposed. With this measurement instrument, which was also completed in 2002 for the German market, a research cooperation between University of applied sciences Magdeburg and the Erlabrunn Clinics gGmbH was reached. Very special thanks at this point to Dr Helmut Röhrborn who is the head

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physician of this hospital and donated very substantial contributions to the further development of Regulative Music Therapy, which is also relevant here. In this hospital we conduct a comparative investigation about alexithymia with clients in verbal psychotherapies and music therapies. This study we called â&#x20AC;&#x153;Alex.â&#x20AC;? The Erlabrunn Clinics gGmbH offer a particularity that so far has not been used for comparative studies of different therapeutic concepts. Here, among other applied therapy concepts, two closed therapy groups with the emphasis on Regulative Music Therapy and dynamic group are conducted, the latter of which is a special verbal psychotherapy concept that is based particularly on the intensive use of group dynamics. For research this is an opportunity to examine comparisons between the results of the different concepts. And this is not conducted in a laboratory environment, but instead uses the particularities of an undisturbed or otherwise influenced clinical praxis. In psychotherapy research since the mid-nineties (Hilliard 1993), as well as in recent music therapy research (Wigram 1999, Wosch 2002, Ridder 2003), the formerly demanded connection between the quantitative research and laboratory environment is broken. It is also possible in a natural setting to work, under newly put questions and perspectives, with quantitative measurement instruments and, for example, to investigate a phenomenon like alexithymia. In doing so, it does not work in these cases of quantitative investigations that occur in a natural clinical setting, to concentrate solely on the verification or falsification of a thesis. It can rather, just as in quantitative research, lead to a hypothesis development at the end of such a research process. This goes also for the Alex study, which will, at the end of my paper, lead to the formation of a hypothesis and then to direct effect studies only on the basis of first results. In the end it is an important question with these special quantitative procedures whether one can find a particular clinical setting that offers a very special suitability for particular investigations. In the case of the Erlabrunn Clinics gGmbH this is given in several respects.

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On the one hand there is a small department of so-called test-nurses, who share certain duties in the implementation and interpretation of the psychological tests with the psychologists. Considering that it is only a small extra effort for the hospital’s capacities of personnel to introduce a new test, as in the case of the Alex study with the TAS 26, and to retain its data for interpretation. With hundreds of patients a year, there is also a large amount of data to be collected, which then has to be differentiated in a second step. With Alex, we are aiming at getting the data of a thousand patients in total; so far we have 308 sets of data. For all patients we also keep further tests, for example the symptom checklist (SCL 90 R), which also can be used for the investigation. Moreover, patients are invited to participate in follow-up groups after one and two years in order to receive information about the further course of the changes that were or were not brought about by the therapies. This can also be combined with questioning through tests, which in turn allows longterm follow-up results to be won. As a third point, Regulative Music Therapy is applied here, which in its theoretical basis already names single aspects of alexithymia. Finally, different therapy concepts are very much differentiated for the

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individual patients here, so that each patient receives various individual therapy offers that are in themselves consistently described and carried out. You can see this on the following slide, which illustrates this point with the example of the two already mentioned therapy groups.

In the bar graphs you can see the temporally different therapy portions that both of the client groups receive in this clinic. Specifically, it means this: For the group with the emphasis on Regulative Music Therapy, 6.5 hours Regulative Music Therapy, which is visible here as the largest portion, 3.5 hours reflecting on the day every evening with music reception and finally 2 hours of active group music therapy are offered. In the other kinds of therapy the relaxation training (autogenous training) with 6 hours a week and sport with 4.5 hours a week are the largest components. The Regulative Music Therapy is here seen as the focus of the therapy setting. Its processes are seen as authoritative for the aims for all further therapies in the coordination of all therapies and treated in the cooperation with single therapists. For the second group the largest part in time, as well as in content, is on ver-

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bal group therapy oriented on group dynamics with 7.5 hours per week. On a time scale this is followed – just as the first group – by autogenous training with 6 hours a week. In this concept the creative therapy comes third with 5.5 hours weekly. You can see very clearly just by looking at the time components that the patients of the Regulative Music Therapy group, as compared with the dynamic group, have a much bigger music therapy portion; on the other hand the dynamic group receives a larger verbal component. Both of these natural therapy settings together with three further settings form the starting point of the Alex study. The other three settings are being modelled more individually for every patient, in which the first of these is for all patients a training in self-perception, the second active music therapy and the third varying concepts of verbal individual therapy / Dyad. In the Alex study we ask for possible differences between the patients treated with different therapy settings with regard to the patients’ diagnostics and special further psychological symptoms. In the end, this general question leads first to my hypothesis formation that is then examined in the clinical praxis without further influences.

Before I come to the general design of the investigation and, with this, to the first preliminary results of the Alex study, I want to briefly introduce the music therapeutical approach of Regulative Music Therapy. It is well known in Germany, though not internationally, which is why I will briefly discuss it here. RMT is a receptive method of music therapy. The development of RMT began at the university hospital in Leipzig, Germany, in the sixties. There the founder of East-German music therapy Christoph Schwabe was entrusted with the practical implementation and theoretical investigations of a music therapy. The most widely used method to date, within his differentiations of music therapy method, is the Regulative Music Therapy. Today it is used as psychotherapy for groups and unfolds in six phases during self perception training. Röhrborn, whom I mentioned above, was primarily involved in its final structure and development. A group session of RMT takes approximately 60 minutes. The session begins with the self perception training accompanied by music, and during this initial phase the patients can be advised as follows: "Try to let your body and the music take over and don't push away the arising thoughts, moods or feelings” (Schwabe & Röhrborn 1996, 60). The group usually consists of 6 to 12 patients who sit comfortably with their eyes closed. Some music, usually one or two symphony or instrumental concert movements, is played for about 10 to 20 minutes. During this time, the patients try to let go and achieve a state of perception, similar to a state of daydreaming, in which they actually start observing themselves. When the music is over they are requested to adjust their physical balance in order to regain the state of full consciousness and begin with the therapeutic conversation. In the course of the conversation, patients speak about their different perceptions. The impact of particular perceptions is strengthened, and since the conversation is held within the group, the patients recall more percep-

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tion details and they are guided and encouraged by the therapist to explore the acceptance in the perception. This leads to a process as outlined in the following slide, which takes, for example, seven weeks in Erlabrunn where RMT is applied every day.

In phase one, as you can see, broad perception takes centre stage: To let go and to accept are the main tasks which have to be performed just like in the first form of Regulative Music Therapy. The focussing of perception on single moments or tensions is replaced by a broad perception of music, body, thoughts and feelings in the centre. If this has been achieved, phase two begins which is based on deep perception. Now single elements such as the beginning of the self perception training or the flow of perceptions shortly before or after the physical awareness are experienced more distinctly and described. A process is initiated in the course of which the capability to perceive one's own inner processes is further enlarged or deepened. In RMT, this can lead to the patient giving a very clear and distinct 10-minute description of a certain moment, which took no more than three seconds in the

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actual training session with music. This is when our selective perception and also our defence mechanisms become unstable. In the following third phase, emotional reactions on perceptions can be observed. Each particular awareness of the body as well as emotional perceptions are now experienced in an emotional reaction. What otherwise is not perceived clearly enough in our daily activities, often for our own protection, is now perceived emotionally with emotional reactions every second.

After this step we begin to differentiate between accepted and not accepted perceptions. In this particular context not accepted perceptions mean that "defensive emotional reactions" (Schwabe & Röhrborn 1996, 65) or the "wish it would be different" (ibid.) are connected with such perceptions. The fifth phase follows immediately, in which we turn to the not accepted perceptions. The "going against" factor of not accepted perceptions is strongly felt by the patients themselves in the course of a precise self-awareness and can be adjusted by them. If patients stop refusing their perceptions, they no longer nurture and sustain them and even start working on particular not accepted perceptions. In phase 6, much emphasis is put on regulation including exercises for daily life, which can be individually practised by the patient. This is, in short, a description of the main procedure and some of the basic principles of RMT. The focus and differentiation of self-perception in RMT was thereby discussed, also before the background of the aforementioned component of alexithymia of an externally oriented style of thinking, where RMT could potentially offer a very good approach. Moreover, as a receptive music therapy RMT offers a proceeding that, gradually, can be oriented very much on the body of the patient as a first description level. The ever further differentiation of the own perceptions, the devotion to not conscious details of inner perceptions between body, thoughts and emotional reactions, can contribute substantially to the therapy of dysfunctions in the identification and description of emotions, as described above for the alexithymia. On the contrary to BMGIM, which is connected from the beginning with symbolisations on the level of images that are just disordered in alexithymia, RMT can show a different approach to the client through the medium of music reception and is especially relevant for the therapy of alexithymia and its fundamental problem of symbolisation. Still, in Alex’s current stadium such a comparison is not the field where alexithymia is being analysed, but the investigation of the above named five therapy concepts of the natural clinical settings of Erlabrunn.

The comparison between the different therapy settings was performed with the following investigation inventory / research design.

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For every patient we raised social data such as age, sex, profession or job, and school qualification. Also an ICD 10 diagnosis of field F, the psychological disorders, was determined as main diagnosis. Furthermore, we established the symptom checklist SCL 90 R and the Toronto alexithymia scale TAS 26. With this investigation inventory the alexithymic problems of all patients were measured, as well as important psychological symptoms with the SCL 90 R, which partially, as described above for alexithymia, reach over to different psychological disorders and give very important information about indication questions besides the ICD 10 diagnosis and the alexithymia values.

And now is the crucial moment â&#x20AC;&#x201C; which preliminary results do we have for our Alex study with the first 308 patients? Before we will be able to see that, we are going to look at the next illustration of the number of patients treated in those five therapy concepts.

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Hereby we reduce the number of 308 to 209 sets of pre-post-data that are as yet completed. For 99 patients we have until now only the pre-test. From the 209 complete sets of pre-post-data, 99 patients were in the self perception training, 31 in each group concept for Regulative Music Therapy and the dynamic group, as well as 24 each in the concept for active music therapy and the different dyads. It is actually pure chance that we have the exact same number of patient data for the Regulative Music Therapy and the dynamic group, and with such an amount it is possible to evaluate the data statistically on the lowest level, which again enables us to make a comparison even between just these two groups. Naturally, though, you need to observe the respectively different profile in the diagnosis of the different groups.

Those are in comparison to the respective rate of their frequency 1 or 2 shown on the following slide.

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I

With the Regulative Music Therapy group, the largest part is characterised by somatoform disorders, followed by depressive disorders. In the dynamic group, on the other hand, anxiety disorders and depressive orders are most prevalent. The self perception training was used as a treatment especially for patients with depressive and personality disorders. Also in active music therapy patients with depressive disorders were mostly getting their psychotherapeutic treatment. Finally, in the verbal dyad there appeared mostly the diagnosis of depressive disorders and somatoform disorders. The largest group of disorders in need of treatment are the depressive disorders, which corresponds exactly with the German statistics of psychotherapy.

Those depressive disorders are being treated with all five concepts, though with the apparent emphasis in the direction of the second diagnosis. This nonexistent homogeneity of sometimes different diagnosis groups in the different therapy concepts needs to be acknowledged with all the consequences for the further evaluation. But the questions about alexithymia allow us to presume different tendencies in just this natural setting and with just these diagnosis emphases. With the different diagnosis profiles as well as with the different therapy concepts we can presume a different

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relevance of the alexithymia problem. The answer to this – and the preliminary results of Alex – will be shown by the next slide.

Here they are. Horizontally you can see in green and blue the individual and summarised scales of SCL 90 and TAS 26. Vertically are the patients, divided into the five therapy concepts. The numbers are the values of significance, which have been, with regard to the characteristics of the data put in, evaluated after the Wilcoxon test (SPSS). In red are those numbers that show a significant change between the pre and post values of the respective SCL and TAS scale within a 5% level. In many cases you can even see the highest probability, a level of 0%. Overall, there is already a tendency emerging by observing the significant red and the insignificant blue numbers. There are considerably more significant changes regarding the experienced symptoms that reported back from SCL. With regard to the central question about alexithymia, only one significant difference can be observed – specifically the concept of RMT. Here the Regulative Music Therapy shows, in respect to significant changes in alexithymia, the highest status. However, this only goes for one

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factor of alexithymia and not for the total. That one factor is the identification of emotions. Such a result was confirmed by an analysis of an individual case, which was conducted by Maren Voigt as her thesis of the University of applied sciences Magdeburg in the psychosomatic department of the University Hospital Magdeburg (Voigt 2003). The identified TAS was determined for a process research program after every therapy session, and also displayed a clear improvement tendency in that factor of identification of emotions in the overall progress of the regulative individual music therapy. The factor of describing emotions did not display that.

The factor of externally oriented style of thinking moved overall in a relatively unproblematic area. Now, with a larger number of patients having been treated with RMT, we can observe an improvement of the factor of identification of emotions also in the clinics of Erlabrunn. This factor seems to play a special role within the construct of alexithymia for the therapy with RMT. There is another parallel between the two studies that is also very interesting: In the single case in Magdeburg the main diagnosis of Morbus Chron was being examined. The close relationship to those somatoform disorders as main diagnosis â&#x20AC;&#x201C; depicted on the slide earlier for the RMT â&#x20AC;&#x201C; is striking and confirms the diagnosis emphases about alexithymia

by Taylor that I mentioned in the beginning. From this we can draw two provisional hypotheses, which will have to be examined during the further course of our study.

Firstly: A) There is a special connection between the diagnosis of a somatoform disorder and the factor of identification of emotions within alexithymia and its therapy through RMT. Secondly: B) For the basic concept of RMT, the identification of emotions is of higher importance than the externally oriented style of thinking mentioned above. What supports this first hypothesis at this time is the fact that the symptom of somatisation experiences in RMT a change to the highest degree (level of 0%). This also happens in the concept of self perception training, which in principle is very similar to the RMT, though working without the application of music reception. These first results suggest, within the alexithymia problem, the highest therapeutic relevance for the RMT. Additionally, the two therapy concepts of RMT and verbal dyad demonstrate a highly significant difference concerning the symptoms depression and anxiety. Looking further at the symptoms, we can complete the totals by determining that the verbal dyad holds the highest average in the prevalues (mean pre=73; post=60), immediately followed by self perception training (mean pre=72; post=63), again followed by the RMT group (mean pre=71; post=64) and just behind active music therapy (mean pre=70; post= 60). In the dynamic group the number only lies at 65 and sinks down to 64, which is not a significant difference. This means that the patient symptoms (determined by using SCL 90 R) have the highest pre-value in the group of patients of the verbal dyad, immediately followed by the self perception training, followed by the RMT group and the active music therapy group. The patients of the dynamic group only show insignificantly heightened problematic symptoms that consequently do not need to

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be worked on – hence we cannot see significant improvements here either. The “lighter” disorders like phobias and anxiety disorder that I named above in the diagnosis emphasis of this group are being empirically confirmed here again. The active music therapy group does not show significant changes in the total values (,011). Therefore a highly problematic symptomatic is being treated foremost in the verbal dyad, the self perception training and in the Regulative Music Therapy. The individually centred concept of Regulative Music Therapy continues – despite group therapy – to become quite clear in the only missing significance in the pathology of interpersonal sensitivity dimension. All three of the just named concepts (verbal dyad, self perception training, RMT) show, however, the highest significant changes in the pathology of depression and anxiety; here seems to lie a commonality in all three of them. One important difference is observed, however, on the one hand with Regulative Music Therapy and on the other with verbal dyad and self perception training. With the RMT an improvement of the alexithymia-factor is achieved, while with the verbal dyad and self perception training there is an improvement of the symptoms, but not necessarily changes in the alexithymia-factor. – It becomes clear with these examples that it is possible to successfully treat very specific psychic problems with very specific therapy concepts. These results can, in an empiric way, lead to a very disorder-specific indication stand about the different therapy concepts. For instance, for Regulative Music Therapy this means the highest effectiveness in treating the symptoms of depression (mean pre=71; post=62), somatisation (mean pre=70; post=64), anxiety (mean pre=70; post=63) and phobia (mean pre=65; post=57) in connection with a partial alexithymia problem (mean pre=62; post=57). This is happening with a considerably better result when compared with the active music therapy in Erlabrunn. Stronger depression symptoms will however be treated more effectively in the verbal dyad (mean pre=74; post=61), although less effectively in connection with partial alexithymia.

In conclusion, this leads us to the hypotheses and perspectives that need to be examined during the further progress of the Alex study.

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It is anticipated that with an even larger number of pre-post-patient-data we can, in the different therapy concepts, compare respectively one diagnosis and one symptom group of patients with similar starting data (N>20). For one thing, this can give the indication for a diagnosis, symptom and alexithymia complex (for example with RMT: somatoform disorder, emphasis on depression and problem of identification of emotions) with one certain therapy concept. This makes a study of effects possible, from practical application and experience and out of an abundance of material, and without having to work in a laboratory environment. This gives the music therapy research new conditions that are much better to realise. Also, for the treatment of such a complex of diagnosis and symptoms there are different therapeutic ways emerging, for example with or without the treatment of alexithymia parts. Within this frame it could further be examined whether the identification of emotions as a theoretic basis of the alexithymia construct will be definitely confirmed within the overall concept of RMT and its particularities compared to the other therapy approaches that have been examined here. Additionally, it is possible to search for further groupings apart from these five therapy concepts by means of a

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cluster analysis, since for all examined patients a significance of 0% for the TAS total value, as well as for the partial factor identification of emotions, had been determined.

References Derogatis, L. R. (1994). SCL-90-R. 3rd ed., Mineapolis: National Computer Systems.

DIMDI (1995). ICD 10. Landsberg/Lech: ecomed-Verlagsgesellschaft.

DSM IV (1996). Göttingen: Hogrefe.

Franke, G. (1995). SCL-90-R. Göttingen: Beltz Test.

Hilliard, R. B. (1993). Single-Case Methodology in Psychotherapy Process and Outcome Research. Journal of Consulting and Clinical Psychology, 61, 373-380.

Kauhanen, J & Kaplan, G. A. & Cohen, R. D. & Julkunen, J. & Salonen, J. T. (1996). Alexithymia and risk of death in middle-aged men. Journal Psychosomatic Research, 41, 541-549.

Kupfer, J. & Brosig, Burkhard & Brähler, E. (2001). Toronto-Alexithymie-Skala-26.

Göttingen: Hogrefe.

Marty, P. & de M’Uzan, M. (1978). Das operative Denken. (“La pensée operatoire”). Psyche, 32, 974-984.

Ridder, H.M.O. (2003). Singing Dialogue. Music Therapy with persons in advanced stages of dementia. A case study design. Aalborg: Institue for Music and Music Therapy Aalborg University. [unpubl.]

Schwabe, C. & Röhrborn. H. (1996). Regulative Musiktherapie. 3rd ed., Stuttgart: G. Fischer.

Sifneos, P. E. (1973): The prevalence of “alexithymic” characteristics in psychosomatic patients. Psychotherapy and Psychosomatic, 22, 255-262.

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References

Taylor, G. J. & Bagby, R. M. (2004). New Trends in Alexithymia Research. Psychotherapy and Psychosomatics, 73, 68-77.

Taylor, G. J. & Bagby, R. M. & Ryan, D. P. & Parker J. D. A. (1990). Validation of the alexithymia construct: a measurement-based approach. Canadian Journal of Psychiatry, 35, 290-296. [TAS 20] Taylor, G. J. & Ryan, D. P. & Bagby, R. M. (1985). Toward the development of a new self report alexithymia scale. Psychotherapy and Psychosomatics, 44, 191199. [TAS 20] Ulich, D. (1992). Wege zu einer personzentrierten Auffassung von Emotionen. In: Ibid. & Mayring, P.: Psychologie der Emotionen. (pp. 49-57). Stuttgart: Kohlhammer.

Voigt, M. (2003). Morbus Crohn und Regulative Musiktherapie. Eine Einzellfallanalyse zur Untersuchung der Bearbeitung von Emotionsabwehr. Magdeburg: Hochschule Magdeburg-Stendal. [unpubl.]

Wigram, T. (1999). Assessment Methods in Music Therapy: A Humanistic or Natural Science Framework? Nordic Journal of Music Therapy, 8(1), 7-25.

Wosch, T. (2002). Emotionale Mikroprozesse musikalischer Interaktionen. M체nster: Waxmann.

Wosch, T. & Frommer, J. (2002). Emotionsver채nderungen in musiktherapeutischen Improvisationen. Musik-, Tanz- und Kunsttherapie, 13 (3), 107-114.

Wosch, T. (2002a). Emotion process measurement of music therapy improvisation.

In Aldridge, D. & Fachner, J. (Ed.). Info-CD Rom IV Music Therapy World. Conferences Napoli, (pp. 1603-1622). Witten: Universit채t Witten-Herdecke.

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Music Therapy Today, Vol. VI, Issue 4, (November 2005) a publication from MusicTherapyWorld.net

CHAPTER 67

Examining Significant music therapy experiences from the perspectives of

individuals living with HIV/AIDS

Young, Laurel

Proceedings of the 6th European Music Therapy Congress

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B. Mus.; BMT; MMT; MTA (Canada) (Portions of this material have been previously published in the Book of Proceedings of the 30th Annual Conference of the Canadian Association for Music Therapy 2004)

Background to the Inquiry This study was completed in conjunction with my master of Music Therapy degree (2002-2003). The topic emerged as a result of eight years experience as a music therapist and Canadian health care professional where my passion for clinical work and my belief that clients’ perspectives must be the main consideration guiding music therapy practice have remained steadfast. I decided to examine work with individuals who are living with HIV/AIDS because of personal interest in this clinical population as well as practical considerations that necessitated a timely completion of the project.

Related Literature The history of HIV/AIDS and music therapy intervention is relatively brief given that anecdotal reports of the illness first surfaced in 1979 (National HIV/AIDS Volunteer Training Kit, 1998). We do not have time today to engage in a detailed review of the music therapy/HIV literature. Notable contributions include: Maranto (1988), Rykov and Hewitt (1991), Bruscia (1995, 1996), Hartley (1999), Neugebauer (1999) and Lee (1989, 1990, 1992, 1995a, 1995b, 1996, 2003). Increased knowledge, earlier diagnosis and better treatments mean that persons who are currently living with HIV/AIDS can achieve longer and healthier lives. Clinical work and literature is currently changing and expanding to address issues specific to those who are actively living with the virus in addition to those who are in the palliative stages of the disease.

Clients’ perspectives on music therapy experiences are sometimes difficult to ascertain as much of the work involves persons who have communication barriers.

To gain a valid and reliable understanding of this area is also methodologically challenging. Investigations or interviews may be considered invasive for some clients or have negative impact upon the therapeutic process. Again, we do not have time for an in-depth review of the literature. Notable contributions include: Aigen

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Methodology

(1995), Arnason (1998), Amir (1992, 1993a, 1993b, 1996) and Lee (1996, 2003). A particularly relevant publication in this area is Inside Music Therapy: Client Experiences, edited by Hibben (1999). There is a need for more literature and sensitive inquiry into clients’ perspectives on music therapy experiences.

Methodology The research paradigm is qualitative, descriptive, explorative and non-positivistic in nature. It does not investigate causal relationships between variables but looks to describe how specific interventions unfold within the music therapy session. The use of inductive reasoning allowed descriptive themes/ideas to emerge with the data as experiences presented themselves. My epistemological viewpoint is based on my belief in each client’s inherent ability to know what he/she needs. These expressed or implied needs are then used to guide the therapist’s treatment approach/interventions within a flexible knowledge base. The research model is multi-methodological and draws upon elements of naturalistic inquiry, grounded theory, phenomenology, phenomenography and hermeneutics.

It was essential to represent each client’s unique perspectives on, and responses to, music therapy experiences that would somehow be identified as important or significant. It was also important that the clinical process remain unaffected by the research. The research questions address these aims: 1.

2.

How do individuals living with HIV/AIDS spontaneously verbalize/respond during/following significant music therapy experiences?

How might the verbal dialogue/responses be organized into categories?

Upon formulating these questions it became necessary to define the term “significant experience”. Similar terms in the literature include “peak experience” (Maslow, 1962; Lowis and Touchin, 2002), “critical moments” (Pavlicevic, 1988), “pivotal” (Erdonmez-Grocke, 1999) and “meaningful moments” (Amir 1992, 1993a, 1993b, 1996). In my study, the music therapy experiences being described and analyzed are a direct representation of what occurred in the “natural” clinical setting as opposed to a formalized research environment. The therapeutic process as it emerged is reviewed with no “after the fact” reflections from the clients. The clinical approach with each client was individualized. It was developed as a result of each person’s expressed and implied needs as well as through the natural evolution of the therapeutic relationship, both musical and interpersonal, over the intervention period. Therefore, it is not appropriate to define or label the experiences in

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the same way for each client. The term “significant” implies that an experience may stand out for an individual but it does not imply the reason why. Therefore, “significant experiences” were defined and identified differently for each client based on the descriptions and analysis of each individual’s unique music therapy experiences and supported by patterns that emerged from the data. This will be further clarified in the Results section.

There were 2 individuals involved in this study, who had (between them) a total of 37, one-hour sessions over an 8-month period. All but 2 sessions were audio recorded and portions of these sessions were analyzed using a method referred to as indexing.1 These notes as well as analytic memos were maintained as part of standard clinical practice and later employed as sources of data. Upon completion of the intervention period, all recorded sessions were reviewed sequentially for the purpose of gaining an overall sense of the therapeutic process for each client. This aided in the formulation of additional descriptive notes and clarified which interventions would be defined and identified as “significant experiences” and subsequently analyzed. This analysis involved the formulation of a thorough description of each intervention using indexing notes, analytic memos, descriptive notes and audio recordings as references. All of the audible responses and verbal dialogue that occurred during and after each significant intervention was transcribed verbatim. The transcripts were analyzed by means of several steps (with reference to Colaizzi, 1978 in Forinash, 1995). Repeated analysis of the transcripts were conducted over 4.5 months in order to gain perspective on the data as well as to force continuous questioning regarding my level of interpretation. Categories and themes were reordered and restructured several times in order to represent each client’s perspective as accurately as possible.

Four criteria as outlined by Lincoln and Guba (1985) were employed to examine the trustworthiness of this study. These include: credibility, confirmability, transferability and dependability. I am happy to answer any questions in this area if anyone requires clarification.

1. “Indexing is a form of evaluation that describes, assess and interprets the music therapy dialogue. Listening back to the session the therapist will stop the tape at salient points, note the counter number and transcribe through words and/or music the meaning and intent of the segment.” (Lee and Khare, 2001, p. 250).

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Results

Results Repeated analysis of the responses and dialogue that occurred during and after ten identified significant music therapy experiences revealed broad categories under which clusters of themes were placed. Separate categories/themes were developed for each client.

Because of time limitations, I will present 2 brief excerpts from the results. It is hoped that a more comprehensive publication of the results will be made available in the future.

EXAMPLE #1

L. is an adult male in his late 30â&#x20AC;&#x2122;s who is living with HIV/AIDS. He struggles with clinical depression and has undergone treatments for cancer in his leg. He has lived in several countries where he has been surrounded by social and political turmoil.

His family has experienced violence and they have suffered significant losses and separations. English is not his first language. L. attended 21 music therapy sessions over an 8-month period where many of these issues as well as day to day struggles and joys were addressed through instrumental and vocal improvisation, singing, song writing, music listening and discussion.

Initially it seemed difficult to choose significant experiences from the sessions with L. and articulate why they could be defined as more significant than others. This was because L. seemed to have consistent responses and possibly meaningful experiences in most of our sessions. However, as the therapeutic relationship progressed, it became obvious that the use of particular interventions gained importance and prominence within the sessions. This was the direct result of requests and choices made by L. Therefore, experiences where these interventions were employed are defined as significant. These interventions include free improvisation, improvisations that incorporated relevant cultural musical material and the use of pre-composed songs. A total of seven of L.â&#x20AC;&#x2122;s experiences were described and the dialogue/responses that occurred during and after each intervention were transcribed and analyzed. Because it was not possible to describe and transcribe all of the experiences where the prominent interventions occurred, experiences were selected where L. chose to engage in dialogue with the therapist after the intervention (not always the case). It is interesting to note that I inadvertently chose examples that seem to be somewhat representative of the therapeutic process in that they begin at session 8 and are more or less evenly spread out over the remainder of the intervention period.

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There was one session where L. said very little as he arrived at the music therapy studio for our scheduled session. He put a large gathering drum and gong by his chair. He began to vocalize a Jewish melody and I joined him using my voice and the piano. This improvisation lasted 30 minutes and the music seemed intense and urgent – particularly when L. spontaneously began to chant prayers in Hebrew. (musical excerpt played here) Afterward, L. explained to me that he was praying for the people of Iraq. This session occurred right around the time the war began. These prayers were all he could offer. He wished he could do more but he had his own battles to fight with HIV. He said, “I have my own war…I am a warrior and everyday I fight with my armour and sword…the music makes me strong.”

An analysis of the responses/dialogue (refer to Table 1) shows an emphasis on embracing the positive and accepting what life has to offer (13 references to C14).

There are also several references to the support/help he provides to others (6 references to C8) as well as the ways in which he helps himself (6 references to C9).

The musical references (Category B) are somewhat evenly spread across themes (24 references to each one). It is interesting to note that even though the improvisation was largely based on fragments of Jewish melodies, there are no verbal references to cultural issues (C13).

L.’s Categories/Themes based on the analysis of the responses/ dialogue that occurred during/after 7 identified significant music therapy experiences TABLE 1.

A. Physical Responses 1. laughing, crying, clapping, sighing…

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B. Musical References (References to:)

C. Personal/ Interpersonal References (References to:)

2.a…the music/instruments used

7…people who support him

in MT sessions 2.b…the lyrical content of music used in MT sessions

8…the help, advice & support he provides to others, his experiences serve as a resource

3…feelings, images, responses evoked by the music

9…his self-reliance, determination & fighting spirit as well as the ability to make his own decisions

4. Use of instrument sounds /singing to demonstrate an idea or make a point

10…day to day/overall struggles & difficulties

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Results

L.’s Categories/Themes based on the analysis of the responses/ dialogue that occurred during/after 7 identified significant music therapy experiences TABLE 1.

5…musical experiences that occur(red) outside of the music therapy setting, includes discussions about musical material not previously offered in sessions as well as personal opinions on music

11…feelings & thoughts, these are reflections of his “personality” & of his “humanity”

6…how music is helpful, important & has the ability to express things

12…conversations & quotes, what others say to him or about him 13…cultural background /experiences/language 14…moving on from the past, enjoying the present and looking towards the future, includes embracing the positive, rejecting negativity, the use of humour and accepting what life has to offer 15…to past & present experiences as well as anticipated events in own personal life 16…to the music therapist, L.’s experiences of MT, the therapeutic relationship, other experiences of therapy

EXAMPLE #2

O. is an adult male in his late 30’s who has been living with HIV/AIDS for over 20 years. He has undergone multiple losses in his life including the fairly recent passing of loved ones. As a child he was subjected to repeated occurrences of sexual and physical abuse that continued into his adolescence. He reports having an unspecified learning disability, which went undiagnosed during his school years. O. has experienced periods of extreme physical deterioration as a result of HIV related illnesses but his current condition appears to be relatively stable. O. attended 16 music therapy sessions over an 8-month period where past and current struggles surrounding the abuse issues were addressed through instrumental improvisation, song writing, music listening and discussion.

In contrast to L., O.’s significant music therapy experiences were readily identifiable and more easily defined. The four identified experiences seemed to contain intense connections and aesthetic responses to the music that did not appear to be present at other times. On separate occasions (with no prompting), O. himself identified three out of four of these experiences as being particularly important/significant occurrences. In all four experiences, O. also demonstrated observable

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emotional responses (i.e. crying), followed by verbal processing (initiated by O.).

Three of these four identified experiences (the 4th was not audio taped) were described and the dialogue/responses that occurred during and after each intervention were transcribed and analyzed. These interventions included free instrumental improvisation and song writing and took place in the mid-late stages of the treatment period (Sessions 9, 13, 14).

Prior to this first identified significant experience, O. had been attending music therapy sessions for two months. His feedback had been positive. He often used the musical instruments to “play out” difficult past and present scenarios. He stated that he felt able to speak more freely and openly in music therapy sessions as compared to other therapies. However, upon listening back to the recorded sessions, it seemed that O. was not engaging with the music itself. I felt that it might be helpful for him to understand that he had the option of experiencing a more intense level of musical engagement should he desire to do so.

The following intervention was formulated and discussed with O. There would be three improvisations during which I would play piano and O. could choose whatever instruments he wished. The first improvisation would be slow. I would begin the music and O. could complement this music in any way that he desired. The second improvisation would have the same format except that the tempo would be more upbeat. The rationale behind this approach was to provide O. with the opportunity to listen, feel and differentiate between two contrasting musical experiences without the responsibility of having to provide them. The third improvisation was designated as O.’s opportunity to lead. He would begin and I would provide support.

The first two improvisations lasted for 22:30 minutes and proceeded accordingly.

Prior to beginning the third improvisation, O. indicated that he wanted to make noise so that he could “get out the frustrations of those damn nightmares”. He initiated loud, solid and steady beating on the conga drums. I joined him on piano. O. had to stop for a moment stating “I’m gonna hurt my hands!”. He reinitiated the improvisation with the snare drum. The drumming became very loud; there was no question that O. was the leader and seemed completely engaged. A climax occurred where an ongoing snare drum roll drowned out the piano where I did manage to establish a melodic theme. Near the end of this 8-minute experience, O. was hitting the gong loudly. He then began to play the djembe drum and went back to the gong.

He stopped and said, “enough of this suffering”. The piano cadenced and the gong faded. (musical excerpt played here)

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Results

As the music faded, O. referred to an image of his abuser. He spoke about his anger, memories of being abused (including his first memory) and his anticipation regarding upcoming events where it would be necessary to face these memories. He spoke about the support he had received from others. He discussed family members, his mother’s sudden death and remembered difficult conversations and relationships. It is interesting to note that several weeks after this experience, O. mentioned that he was sleeping much better and could not remember having any more nightmares.

An analysis of the responses/dialogue (refer to Table 2) shows that all of the categories/themes, with the exception of references to the music (B2), occurred several times throughout the dialogue. Highly prominent themes occurred in Category C (personal references /self-expression) where painful events (45 references to C10) and expressions of hurt, pain, anger and frustration (21 references to C5) dominated the conversation. Other notable areas included 13 identifiable physical responses (Category A1), references to others (a total of 27 references in Category D) as well as requests for understanding and help (a total of 27 references in Category E, themes 14 & 15).

O.’s Categories/Themes based on the analysis of the responses/ dialogue that occurred during/after 3 identified significant music therapy experiences TABLE 2.

A. Physical Responses 1…laughing, crying, feeling hot, sighing, pain, biting tongue…

B. Musical References (References to:)

C.Personal References /SelfExpression (Expressions of:)

D. References to Others (may/ may not involve self)

E. Request(s) /Desire(s) /Need(s)

2…the music

5…hurt, pain (physical & emotional), anger (revenge), frustration

12. References to others’ losses, pain, similar situations

14…to be understood, believed, supported, loved

3…feelings

6…strength, pride, determination (fighting back)

13. References to

15…for help (to understand, to get through difficult times, involves more than moral support)

/reactions evoked by the music

/explanations for behaviors, actions, inaction, thoughts, qualities, feelings of others

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O.’s Categories/Themes based on the analysis of the responses/ dialogue that occurred during/after 3 identified significant music therapy experiences TABLE 2.

4. Use of instruments /sounds to demonstrate an idea/make a point

7…negative self-image, inability, regret

16…to live his own life; to accept and move on…

8…fear (past, present, anticipation)…

9…grief, sadness, loss

10.

References to painful events / memories…

11.

References to day to day/normal life…

Comparative Discussion In the final research paper, comparisons and contrasts were made between the experiences of the two individuals. Areas of discussion included: 1.

2.

3.

4.

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Discussion and Conclusion

This information may contain elements of transferability if the participants are considered to be typical cases with distinct perspectives. References were also made to the literature.

Discussion and Conclusion In the final research paper the following areas were also addressed: 1. Methodological Considerations

• Authenticity • “researcher-as-instrument” 2. Implications for Music Therapy Practice

• • • •

Practice Based Research Consideration of clients’ perspectives in music therapy practice Music therapy with persons who are “actively” living with HIV “listening back” to sessions

3. Recommendations

• • • •

More research on clients’ perspectives on music therapy experiences More research on music therapy and persons living with HIV/AIDS Group music therapy for those infected/affected by HIV Training considerations for music therapists

Selected References Aigen, K. (1995). Here we are in music: one year with an adolescent, creative music therapy group. Nordoff-Robbins Music Therapy Monograph Series. New York University.

Amir, D. (1992). Awakening and expanding the self: Meaningful moments in the music therapy process as experienced and described by music therapists and music

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therapy clients. Doctoral Dissertation, New York University. UMI Order # 9237730.

Amir, D. (1993a). Moments of insight in the music therapy experience. Music Therapy, 12(1), 85-100.

Amir, D. (1993b). Research in music therapy: Quantitative or qualitative? Nordic Journal of Music Therapy, 2(2), 1-13. Retrieved July 24, 2003, from htt:// www.hisf.no/njmt/amirresearch.html.

Amir, D. (1996). Experiencing music therapy: meaningful moments in the music therapy process. In M. Langenberg, K. Aigen & J. Frommer (Eds.), Qualitative music therapy research: Beginning dialogues (pp. 109-129). Gilsum, NH: Barcelona.

Arnason, C. (1998). The experiences of music therapists in an improvisational music therapy group. Unpublished doctoral dissertation, New York University.

Bruscia, K. (1995). Images of AIDS. In C.A. Lee (Ed.), Lonely waters: Proceedings from the international conference, music therapy in palliative care (pp.119123). Oxford: Sobell.

Bruscia, K. (1996). Embracing life with AIDS: Psychotherapy through guided imagery and music (GIM). In K. Bruscia (Ed.), Case studies in music therapy (pp.

581-602). Gilsum, NH: Barcelona.

Erdonmez-Grocke, D. (1999). Pivotal moments in guided imagery and music. In J. Hibben (Ed.), Inside music therapy: Client experiences (pp. 581-602). Gilsum, NH: Barcelona.

Forinash, M. (1995). Phenomenological research. In B. Wheeler (Ed.), Music therapy research: Quantitative and qualitative perspectives (pp. 367-387). Phoenixville, PA: Barcelona.

Hartley, N. (1999). Music therapist’s personal reflections on working with those who are living with HIV/AIDS. In D. Aldridge (Ed.), Music therapy in palliative care: New voices (pp. 105-125). London and Philadelphia: Jessica Kingsley.

Hibben, J. (Ed.). (1999). Inside music therapy: Client experiences. Gilsum, NH: Barcelona.

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Selected References

Lee, C.A. (1989). Structural analysis of therapeutic improvisatory music. Journal of British Music Therapy, 3(2), 11-19.

Lee, C.A. (1990). Structural analysis of post-tonal therapeutic improvisatory music.

Journal of British Music Therapy 4(1), 6-20.

Lee, C.A. (1992). The analysis of therapeutic improvisatory music with people living with the virus HIV and AIDS. Unpublished PhD thesis, City University, London.

Lee, C.A. (1995a). The analysis of therapeutic improvisatory music. In A. Gilroy & C. Lee (Eds.), Art and music: Therapy and research (pp. 35-50). London: Routledge.

Lee, C.A. (Ed.). (1995b). Lonely waters: Proceedings from the international conference, music therapy in palliative care, Oxford: Sobell.

Lee, C.A. (1996). Music at the edge: The music therapy experiences of a musician with AIDS. New York: Routledge.

Lee, C.A. (2003). The architecture of music therapy. Gilsum, NH: Barcelona.

Lee, C.A. & Khare, K. (2001). The supervision of clinical improvisation in aesthetic music therapy: A music-centered approach. In M. Forinash (Ed.), Music therapy supervision (pp. 247-270). Gilsum, NH: Barcelona.

Lincoln, Y. and Guba, E. (1985). Naturalistic inquiry. Beverly Hills: Sage.

Lowis, M.J. & Touchin, C. (2002). An investigation into music found to trigger peak emotional experiences during controlled listening experiences. British Journal of Music Therapy, 16, 35-45.

Maranto, C.D. (1988). AIDS: Information and issues for music therapists. Music Therapy Perspectives, 5, 78-81.

Maslow, A.H. (1962). Lessons from peak experiences. Journal of Humanistic Psychology, 2, 9-18.

National HIV/AIDS Volunteer Training Kit (1998). An overview of HIV/AIDS. Toronto: AIDS Committee of Toronto.

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Neugebauer, L. (1999). Music therapy with HIV positive and AIDS patients. In D. Aldridge (Ed.), Music therapy in palliative care: New voices (pp. 126-134). London and Philadelphia: Jessica Kingsley.

Pavlicevic, M. (1988). Describing critical moments. In S. Hoskyns (Ed.), The case study as research: Proceedings of the fourth music therapy day conference (pp.3133). London: City University.

Rykov, M. and Hewitt, G. (1991). Last songs: AIDS & the music therapist. Toronto: Music Therapy Services of Metropolitan Toronto.

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Music Therapy Today, Vol. VI, Issue 4, (November 2005) a publication from MusicTherapyWorld.net

CHAPTER 68

Perspective of Music Therapy in Italy: past, present and future. A

search for a national identity.

Zanchi, Barbara; Suvini, Ferdinando;

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Ferrara, Carmen; Bodrato, Barbara; Borghesi, Massimo; D’Ulisse, Emerenziana & Casotti, Andrea A.I.M. (Associazione Italiana Professionisti della Musicoterapia) – Italian Professional Association of Music Therapy

Today’s paper aims to present the cultural and professional situation of music therapy in Italy and, by going back over the most important stages in its historical development, to outline some possible paths for the future.

Historically describing the development of a discipline such as music therapy can be a means of asking ourselves about the meaning and the role of this approach to the human condition of difficulty and/or pathology. This is the background question that has by now been posed for several years in the search, not only in Italy, for a definition of the discipline at different levels. Over the years, this debate, which is still very active in Italy, has contributed to recognising and formalising aims, theoretic reference models, intervention plans and areas, methodologies and ethical criteria for the various music therapy approaches.

Since the start of its history, Music Therapy in Italy has developed around intuitions, epistemologies and institutions oriented towards two different areas of cultural reference: the medical/psychiatric-psychological one and the artistic/musicaleducational one. For many years these two origins and perspectives of Italian music therapy entered into a heated and conflicting debate for the supremacy of the aspect which each considered to be the constituent and fundamental element of the discipline, specifically the relational element for the first and musical experience for the second.

As in many countries, the first steps of every new discipline always need some pioneers who, in order to be such, must have strong and charismatic personalities which, in the earliest stages of development, are an invaluable resource, also in terms of the intransigence with which more often than not they defend the “orthodoxy” of their thinking.

This process started halfway through the 70s with the first occasion for national comparison at the Bologna Conference in 1973. A few years later Nora Cervi, at the time director of the Music Course of the Pro Civitate Christiana of Assisi and a per-

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son endowed with a rare sensitiveness, kindness and far-sightedness, unfortunately recently passed away, made herself the founder, together with a group of collaborators, of the first Italian Training Course which started, as an experiment, in 1981.

For about ten years this initiative was the point of reference for music therapy in Italy, the melting pot for many considerations, elaborations, discoveries, encounters and confrontations. For many of us, Assisi represents the origin, the point of departure from which many of the training and professional experiences that later developed and are currently present in Italy started off.

It was during these first ten years that the debate on the multidisciplinary aspects of music therapy became very heated in the perhaps still somewhat naive search for the “essential component” rather than the most suitable reference “model” or “area of application” for music therapy.

It was still thought that one “music therapy” existed, whereas thankfully over the years it was revealed that many possible and effective music therapies could be identified. During those years there were numerous factors that contributed to the development of music therapy both as an area of practice and as an area of knowledge. On one hand was the growing number of trained music therapists who gradually began to spread music therapy into new areas of application and make it known to other professional categories with whom they were then able to confront themselves and their different areas of knowledge. On the other was the increasing contact with representatives of music therapy in Europe and America who contributed to enriching the wealth of knowledge and theoretical references, also thanks to the increase in the circulation of original and translated texts (for example, the writings, lessons and supervisions of Alvin, Benenzon, Bruscia, Bunt, Lecourt, NordoffRobbins, Priestley and Wigram).

Music therapy gradually became a recognised and accredited practice spread throughout the country and music therapists began to be present and appreciated within the various social-educational, rehabilitative and therapeutic teams.

In the commotion caused by such a development it is normal that the more responsible operators start to feel the need for regulation of the profession in order to protect against the use of a proliferation of unreliable figures and defend themselves as professional figures. The first associations emerged which, having also the objective of cultural promotion of the discipline, started to gather groups of professionals at a local level who felt the need for more confrontation within the discipline and to see the recognition of what by this stage was for many their main occupation, but

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which often had to be assimilated into more general or different professional roles in order to fit into the various work contexts.

Over the years the form of associations has also become an identifying element in relation to the various positions that are by now widely represented and more communicative in the Italian music therapy field.

The real possession both of good musical abilities and of an psychological interpretative model of musical relationship are by now unanimously recognised as being necessary qualities for a music therapist, though with the different emphasis that the various schools place on one or the other.

Thus, both psychodynamic-oriented music therapies and humanistic-existential relational music therapies currently exist as the two main prevalent directions. The emphasis that is placed on the quality of the musical experience, even within the same orientation, is still rather variable. Other than a good level of musical ability and knowledge, which by now all schools request of aspiring music therapists, for some also indispensable is the quality of the musical experience and a style of encountering this experience that the music therapist must have recognised in him/ herself in order to be able to become credible witnesses in the therapeutic relationship. Although not many schools make this request yet, it anyhow seems that this will be the path of future development in relation to the specificity of music therapy compared to other approaches for helping people.

Returning to the historical reconstruction, at the beginning of the 90s the various Regional Associations, which in the meantime had spread considerably, decided to join together to form the Italian Confederation of Music Therapy Associations (Confederazione Italiana Associazioni di Musicoterapia - Conf.I.A.M.) with the objective of including and coordinating the initiatives which were more and more often being proposed in Italy. These initiatives can be classified into the following areas: Informative and for dialogue, Educational, Clinical and Research.

In relation to the first point, information and dialogue, study days, conventions, conferences and publications were promoted on a national level.

In this sense, the Italian Music Therapy Conference took on particular importance.

It has been organised every 2 years since 1994 (Ercolano ‘94 , Portoferraio ‘95, Turin ’97, Florence ’99, Naples ’01, Rimini ’03) and allows an internal dialogue and confrontation to be developed between the various positions and practical approaches which are taking shape in the music therapy scene in our country.

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The Conferences mentioned have also been an opportunity to distribute publications both coming from the international scene and from the abovementioned lines of thought that are more and more clearly taking shape.

A great deal of attention has been paid to the definition of educational criteria. The Associations have promoted local undergraduates Training Courses as well as some postgraduate experiences throughout Italy. Coordination on a national level has allowed identification of some fundamental criteria for organising the educational programme for the undergraduate courses, circulated via their publication in the Student’s Handbook in 1999.

In short, the criteria are the following:

• Length of Training Course at least 3 years (from 700 to 1400 hours); • Entrance criteria: Secondary school and good knowledge of musical language; • Educational Programme divided into 4 areas: Music Therapy (45%), Music (25%), Psychology (15%) and Medicine (15%);

• Practical placement (minimum 250 hours) and Tutoring (minimum 60 hours); The coordination and monitoring of the courses have produced excellent results in terms of educational standardisation. Collaborations and conventions are currently underway between the training courses and music conservatories and universities with the aim of improving the quality of the courses and above all avoiding the danger of self-referencing which is always present in privately managed Courses.

With reference, lastly, to clinical and research areas I would simply like to indicate how far music therapy practice is spreading to more and more varied areas and how this quantitative increase corresponds to a similar significant qualitative improvement also confirmed by the as yet not numerous but still significant presence of research projects which have the advancement and improvement of clinical practice and the application of music therapy among their main aims.

Within this reference framework, the Italian Professional Association of Music Therapy (A.I.M.) was set up in June 2002.

The association’s main objectives are the recognition of the professionalism of those who work in this sector and safeguarding the correct practice of their profession.

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Among the various aims that the Association has set itself we would like to point out the following aspects:

• Managing a National Register of Music Therapists comprising three sections:

List of Music Therapists, List of Music Therapy Educators and List of Supervisors;

• Establishing and raising clinical and ethical standards; • Being a constant point of reference for all music therapists in Italy; • Guaranteeing the correct practice of the profession by the members of the Register;

• Safeguarding the collective interests of the sector providing consultancy and support;

• Encouraging the spread of updated information on job opportunities and new work agreements;

• Encouraging the exchange, publication and distribution of works relevant to music therapy;

• Establishing and maintaining contact with other music therapists and associations around the world;

• Maintaining a continuous relationship with the other related professional associations.

In the pursuit of these aims, a ‘Collegio Probi Viri’ has been nominated which will verify that the registered professionals observe the standards in the Code of Ethics.

Of particular importance is the fact that 3 specific Registers (Music therapists, Teachers and Supervisors) have been identified, and the relative entrance criteria for all three Registers have been identified and defined: REQUISITES FOR INCLUSION IN THE REGISTER OF MUSIC THERAPISTS

• To have obtained a Diploma in Music Therapy from a training school recognised by the A.I.M.;

• To have carried out, after the Diploma, at least 60 hours of Supervision with a

Supervisor recognised by the A.I.M. over a period of at least 12 months and in reference to your own clinical work;

• To have passed a qualifying examination consisting of a written test analysing a case (preventive or rehabilitative);

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• The criteria for permanence in the Register have at present been identified as a

minimum of 30 hours of professional updating courses to be carried out during the three years of membership of the Association.

REQUISITES FOR INCLUSION IN THE REGISTER OF MUSIC THERAPY TRAINERS

• Having a Degree (in medicine, psychology, social-education, music and Conservatory)

• Having been in the register of music therapists for at least 5 years • At least 5 years of professional work (at least 1600 hours in total) • At least 60 hours of supervision (5 years under the responsibility of an A.I.M. supervisor);

• At least 2 articles or publications on music therapy and published in contexts of the medical, psychological, social-educational, musicological and music therapy sectors.

• At least 1 paper on music therapy presented at national or international conferences

REQUISITES FOR INCLUSION IN THE REGISTER OF SUPERVISORS

• Having a specialised Degree (in medicine, psychology, social-education, music) • At least 10 years of supervised professional work with permanence in the A.I.M. register

• At least 5 articles or publications on music therapy and published in contexts of the medical, psychological, social-educational, musicological and music therapy sectors.

• At least 3 papers on music therapy presented at national or international conferences

• At least 2 years of personal dynamic music therapy in a small group or individually (40 hours annually); alternatively, 2 years of individual psychotherapy c/o a professional accredited by a psychotherapy association recognized by the State.

Currently the Association numbers approximately 150 members evenly distributed throughout the country and coming from all of the various Training Schools;

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Although it is not the only professional association existing in Italy (at the moment two associations are registered in the EMTC), the A.I.M. currently represents as a body the highest number of music therapy professionals from various orientations.

It is present and active in the process of recognition at a national legislative level within the CNEL (Consiglio Nazionale Economia e Lavoro - National Council for Economy and Labour). The association’s aim is that music therapy be counted among the new professions in the socio-medical sector whose practice will be regulated and recognised by the respective professional associations who have been entrusted with this task by the government.

In reference to this important objective of the express Recognition of Music Therapy, we would like to briefly outline the problem, to go over how this process has taken shape in our country and to identify the path that can lead to obtaining this recognition.

The intellectual professions, of which music therapy is one, represent the most dynamic and growing part of the labour market and the professional competences represent a fundamental element of modern social organisation.

For these reasons over the centuries the intellectual professions have been protected by legislation in which corporative interests and the government’s desire for control coexist in an alternation of government activism and autonomy.

The origin of the regulations, created via professional Rolls and Registers, is found in the recognition by the government of a specificity of the intellectual professions and their ability to have an effect on interests central to the stability of society.

At present, the fragmentation of knowledge has made new needs emerge: numerous new professional figures have joined and are joining those who have traditionally had recognition and regulatory control.

In a versatile and continually changing context, the professional system in our country thus calls for significant revision, reorganising and regulations.

The existing professional Registers must accept the idea of modifying their structure in order to update and adapt them to recent transformations in the professional world while we will have to continue with the recognition of the representative bodies (Associations) of just as many professional activities.

Bodies that can guarantee suitable levels of qualitative control regarding professional competence and ethics.

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Conclusion

The debate that has gone on at a professional level between the sectors involved has allowed an important agreement to be reached on some basic principles of the reorganisation of the professional system in Italy.

Numerous Bills, proposed by the Ministry of Justice which has jurisdiction on the matter of the regulation of Professions, refer to a general reorganisation of professional aspects and mention the Professional Associations as bodies that can identify, maintain and raise the Professional quality practiced by the individual Associations.

As all the elements required to proceed have been acquired during the previous legislation, the logic of the matter would have Parliament approve the Reform for the Recognition of the professions in a reasonably short time.

This Recognition would lead to the entry of the Association in an appropriate register, under the care of the competent Ministry, followed by a verification of the requisites of the recognised Association.

Conclusion In conclusion, we would like to emphasise that the process largely identified anticipates that the educational aspects, entrusted to the Conf.I.A.M., and professional practice, entrusted to the A.I.M., must translate into complementary and communicating aspects of a single reality which aims to improve the professional quality of the music therapists involved.

This quality is maintained and raised through the ability to listen to the general problems of members and to meet with them in the face of difficulties in the practice of the profession as well as taking care of and encouraging the exchange and spread of information.

It is in this direction that the A.I.M. and Conf.I.A.M. have organised for this occasion a special issue of the journal which brings together some of the projects from the last few years in English as an exemplification of what we have illustrated here.

We would like to highlight that, pending a definitive recognition of the music therapy profession following the approval of the special Bill, the process so far identified will in any case have an immediate effect on internal regulation and recognition.

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The creation of a Register in which people who have followed an accredited Training course and have started to practice the profession following quality certification criteria can enrol is a sign of seriousness and maturity that allows us to think optimistically about the path that will lead to Recognition.

A valid process of Professional Recognition can be planned and carried out by bringing the best human resources into play with the firm belief that, as clearly highlighted in the Directive issued by the European Community, they are proposing a useful service to the clients, from socially fragile areas, that music therapists devote themselves to in their work.

As we all well know, the search for identity is a dynamic process with many steps to be covered. Just as it is useful at times at a personal level to become more aware of the distance you have travelled in order to have the trust and respect for the part you still want to travel, also in the search for a dynamic identity for music therapy in Italy we are aware of not being so small any more and of having covered a demanding but important stretch of road…… and, jointly, of really wanting everything that is still left to do and to discover.

We would like the spirit with which we will travel the “next part” to be a bit less dictated by demanding and idealistic contrasts and much more abounding in mutual listening and cooperation.

As always in our work words convey the sense of an experience that we have lived or that we want to live much less than music. We would like to conclude with a piece of Italian music in which each of us can find echoes from the past and signs for the future.

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Music Therapy Today, Vol. VI, Issue 4, (November 2005) a publication from MusicTherapyWorld.net

CHAPTER 69

Music therapy with adolescents in Italy

Zanchi, Barbara & Cordoni, Luisa MusicSpace Italy, Bologna, Via Saragozza 18. email: musicspace@inwind.it

Introduction In this paper we would like to present some reflections on the music therapy project that we have been carrying out for some years with adolescents for MusicSpace Italy, the Italian branch of The MusicSpace Trust.

Although a daily habitual contact with music seems to be one of the key identifying features of adolescents of our times ( IARD 1996) it has only been in the last few years that music therapists in Italy have turned their interest to this important transitional phase of life in developmental and psychopathological contexts. Since the 1980s there have been numerous studies and research projects in the fields of musicology and psychology of music on adolescence and music, but it was only towards the end of the 1990s that the first accounts of specific music therapy projects appeared in Italy with adolescents in psychiatric day centres and in situations of

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risk of deviancy in school (Zanchi 1999, Violi and Draisci 2000, Cordoni 2002) as well as young drug addicts with associated mental disorders (Postacchini 2002).

Our work was one of the first experiences in Italy of music therapy with adolescents attending psychiatric day centres and in situation of communicational and behavioural problem in school.

Over the last seven years this experience has involved 220 young people aged 13 to 18, mostly males.

Adolescence and music The meeting between an adolescent and music can develop along extremely variable paths resulting from the numerous ways in which the typical features of emotional and mental functioning at this age interact with forms of musical experience .

One of the most vivid features of adolescence is the experience of the loss of the childhood that the adolescent is breaking away from, an experience which proceeds in parallel to the frantic search for confirmation and reassurance of their sense of identity and of their future. Tendencies to idealize and over-intellectualise aided by the maturation of cognitive processes are combined with an emotional-affective level that is still very unstable. Together, these produce a widespread state of confusion and ambiguity between developmental stimuli and regressive tensions (Meltzer 1981).

This aspect of unstable self-perception leads the adolescent to seek a group of peers as a model and container for his/her very important “proofs of identity”, as a place of reassurance / validation and as a group to compete and compare himself against.

(Ricciotti 2004). It is in precisely this context that, for an adolescent, music takes on a function of reinforcement of personal identity and of mediator and facilitator for interpersonal communication. At times, music may also act as a catalyst for the dimension of wanting to belong and cause a renewed investment in the world which can rescue the adolescent from the dangerous tendency to withdraw into himself.

The other part of our interest is the structure of the musical dialogue, its form and some elements which we consider relevant in understanding the relationship that adolescents enter into with music.

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Adolescence and music

In recognising the sense of a musical work, elements connected to its origin and the processes put into action by the listener jointly come into play.

Music does not only carry acoustic information; in fact, every human being recognises different emotions, thoughts, sensations and images in music. Music does not signify, but it suggests; it has a sense but not a meaning (Imberty 1986).

Furthermore, built into its structure, music has the ability to relate contrasting and ambiguous elements, conflicting themes, temporal and dynamic contradictions, stimuli that are multiple and non-specific at the same time, without being forced by its nature to make a choice and without jeopardising its communicative power (Gaita, 1991).

To translate musical sense, each individual thus proceeds in his own way through the always-different experience of the subjective meeting between musical form and mental life (Ricciotti, 2000). â&#x20AC;&#x153;Unlike verbal language, music and art offer the client a language which does not indicate meanings in an unequivocal way, which does not define but which, through the analogical power of symbols, suggests connotations with multiple, open meanings. It would appear that this polysemy of the languages of the arts inevitably coincides with some of the typical traits of adolescence and allows the coexistence of apparently contradictory thoughts and states of mind, activating projective mechanisms which tend to fill the ambiguity of the form of the stimulus with mental and emotional elaborationsâ&#x20AC;? (Corraini, Zanchi 2001)

From the study of some of the typical ways in which adolescents use music it was seen that these ways sometimes correspond to precise personal features, listening and lifestyles. In general, a fluctuation is seen between more passive and more active extremes, or between a more consumerist type of use and a more creative one (Manarolo 2004).

For a certain type of adolescent, in fact, music represents a space in which impulse and a lack of criticism, the influence of fashion and abandonment to excitement and amazement are predominant. He looks for music which stimulates the senses, that he can merge with and which envelops his body, not leaving any spaces which could let him feel his needs and tension. The main listening style is observed in a regressive state and is linked to the type of functioning as in Bionâ&#x20AC;&#x2122;s basic assumptions as well as to defence mechanisms such as schizo-paranoid type, adhesive or projective identification; space for symbolic elaboration is not tolerated at all.

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This listening behaviour is characterised by stasis, lack of change and immobility, also obtained as the paradoxical result of repeated and stereotyped movements.

Symbolisation and individuality disappear and there is a massive activation of the background in the form of circular, empty repetitiveness.(Tagg, 1993).

The experiences of escaping from realty and desynchronisation from the spatial/ temporal perception of daily life that are sometimes caused make this modality of using music similar to some toxicomania behaviours.

Another possible means of using music concerns those adolescents who consider music to be an opportunity for self-expression, for healthy retreat from ordinary thoughts, for identification with the writers singers, for choice and for refining their own artistic sensitivity. This relationship with music becomes manifest when “the desire and the ability to sort through the mass of sensations which the sounds stir, acquiring, as the final stage in a hypothetical journey, performance and creative skills” manages to emerge from the more passive means of using music (Frontori, 1992).

This time the listening style occurs in a progressive state and is connected to a type of functioning which focuses on the completion of a task and which uses defence mechanisms such as introjective identification corresponding to a mental position that is more elaborative and sufficiently harmonious to be able to attune to the real profundity of another person’s feelings (Postacchini et al., 1997).

This different type of behaviour is characterised by openness to the idea that listening can bring about a change, the capacity to recognise variations and an interest in identifying formal elements in the musical dialogue. There is the possibility to perceive those “happy forms” or qualities of music (Gaita 1991) that can directly evoke feelings and emotions through symbolic association.

Experiences with the adolescents The music therapy project that we are going to illustrate specifically emerged from our interest in investigating the styles of relating to the musical experience, listening and playing, with the hypothesis that these styles might correspond to as many different, more or less troubled lifestyles. For a young person to enrich the quality of her/his relation with the musical experience may sometimes represent the only way to discover new “styles” to relate to herself/himself and to the world.

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On previous occasions we have looked at the clinical projects (Zanchi, World Conference Proceedings, Oxford 2002) which since the end of 1997 have involved approximately thirty adolescents who regularly visit a psychiatric day centre in the North Italy and who suffer from serious psychopathological disorders; on this occasion we would like to focus our attention on music therapy projects carried out with young people in secondary schools. These projects, which were started up after the clinical-therapeutic projects, were of short to medium duration (from four to ten sessions) compared to the earlier ones (from one and a half to three years with weekly sessions) and were carried out in a group setting rather than an individual one.

Far from wanting to integrate such different experiences, our intention is to reflect on the possibilities that music therapy can offer in the identification and optimisation of personal listening styles in the belief that it can significantly influence the self-organisation of life styles and give rise to an expressive and creative desire, especially in adolescence; this is both in situations of psychopathological disorder and not.

The music therapy groups with the adolescents This music therapy experience was started up in the Technical High School in a town in Central Italy, and it goes back to a pilot project set up three years ago as a result of the need to find strategies to prevent the problems and maladjustment which often cause situations of high drop-out rates from school and forms of juvenile deviancy. The request for intervention came from the schoolâ&#x20AC;&#x2122;s management and the teachers with the aim of improving their increasingly difficult and demanding communication with students.

Due to a cultural/social background which is not very considerate of adolescent problems and rather isolated geographical origins, the young people who go to these schools often have trouble expressing themselves and, in particular, they find it difficult to use verbal means to voice their experiences, tastes, desires, disquiet, anger and anxieties. These experiences either emerge via a lack of control or through strong inhibitions, both situations that do not allow the person to acquire formative tools which are useful for a harmonious growth process.

More and more often, the only solution these young people find to the problems mentioned above is giving up school early. As in many other European countries,

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our country has registered the spread among adolescents of aggressive behaviour and a growing difficulty on the part of educators to implement effective strategies.

More and more often, teachers request interventions of support for teaching activities due to the growing difficulty in relating to these youngsters. They request supplementary projects which require the presence in the school of experts in the field of relationships and communication in order to find new tools for improving the quality of relationships with and comprehension of their students.

The project started in Autumn 2001 with a preliminary investigation carried out among the students of about ten classes in which an open question was set to gather information on the representations that the adolescents had of their personal “experiences” of music (H. Smeijsters in Wigram, Sperston, West 1995).

In all, the interview involved 110 youths between 15 and 18 years of age.

The request made was to write the sensations, emotions, sense, or simply whatever came to mind following the sentence: “When I listen to music…”

The time available to write the answer was five minutes and anonymity was guaranteed.

While studying the replies we intended to define a hypothesis on the main styles of use of musical experience in the adolescents, a central element that we intended to investigate and work on later in an interactive musical way. The answers that could be attributed to consumerist and not very elaborative listening / use behaviours were by far predominant. Below we have recounted some of the answers obtained: GROUP FOR WHICH MUSIC IS ABOVE ALL A SPACE WHERE IMPULSE AND LACK OF CRITICISM, ABANDON TO EXCITEMENT, AMAZEMENT, THE INFLUENCE OF FASHION AND A MORE PASSIVE EXPERIENCE ARE PREDOMINANT:

“WHEN I LISTEN TO MUSIC………”

• I sing, I shout, I relax (Luca, 15) • I remove all the worries from my mind. I don’t think about anything. (Andrea, 16)

• It depends what I’m doing. If I’m lying on my bed I fall asleep more easily, if

I’m playing car games on the computer my adrenalin level goes up and I let off steam trying to corner like a madman. (Maurizio, 15)

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• It blows my mind (Mauro, 16) • For me, listening to music is also a chance to relax, actually I should say most of all a chance to relax because I usually get a sensation that almost seems like not thinking about anything. (Luca, 17)

• When I listen to music I feel good, I feel like I’m flying, I’m in a world of my

own with my thoughts and I get really worked up, especially when it’s disco or Latin American music. When I listen to music I start to daydream about the piece I’m listening to. Music makes me feel at peace, with myself and it makes me forget school, tests, homework, etc. for a moment.

I think that music is essential in the life of a teenager. (Francesco, 16)

• My mind frees itself of the thoughts that worry me during the day.

For me, music causes a period of relaxation that starts from my head and then goes right through my body.

For me music is life. (Andrea, 17)

• I feel better, like I’m in another world, I don’t think about my problems any

more.Each type of music I listen to matches one of my states of mind and one of my fantastic fantasies.Even my sadness, immersed in music, disappears and I can think better. (Marco, 17)

• First of all, depending on the day I’ve had or I have to face I listen to a certain

type of music. If I have to gear myself up I put on “aggressive” Rock or if I’m down I put on a calmer kind of music, always strictly Rock. (Domenico, 18)

• I get sentimental. If I’m in a bad mood and I listen to “tranquil” music, I calm

down. Different kinds of music change my feelings.

There are so many things to say that a whole exercise book wouldn’t be enough.

So, I like music! I like it a lot! (Giovanni, 17)

GROUP FOR WHICH LISTENING TO MUSIC AS AN OPPORTUNITY FOR SELF-EXPRESSION, DECENTRALISATION FROM ORDINARY THOUGHTS, IDENTIFICATION WITH THE SINGER, A MORE CREATIVE EXPERIENCE IS PREDOMINANT

“WHEN I LISTEN TO MUSIC……...”

• When I listen to music I think that I am the singer, I’m on a stage with millions of people and I feel like I can hear the audience applauding me and loving me, screaming my name at the tops of their voices. It makes me feel important.

(Andrea, 16)

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• I feel better and I enjoy myself, I experience extraordinary emotions and I think about the singer’s emotions and I feel them in me. (Paolo, 16)

• I can take on different identities, I mean, if, for example, I’m lying on my bed I

relax, or if that particular music reminds me of something important, I think about it again in lots of different versions.

On the other hand, when I’m doing a physical activity I can load myself with adrenalin (at least I think so) and as a result I can work for longer at the peak of my motor abilities.

Still other times, depending on the work I’m doing, I can concentrate at my best.

For example, I think: if it’s a love song, about a girl, if it’s about a journey I would listen to it all the time, because I identify with the journey that the singer has written. (Filippo, 17)

• I travel in my mind.

I feel really strong emotions being stirred up in me, to the point that I start to sing, thinking about the things that have happened to me before in my everyday life.

• I live. I feel free from any dogma, I am free to think whatever I like.

I play and this allows me to leave all my problems behind me.

I listen to everything: from opera (Carmina Burana) to metal (Anastasia, Rapsody), they are very different from the usual kinds of music because they have an orchestral base, but played with instruments that are used in Metal.

This characterises me and at times it isolates me.

But when I find someone who listens to my kind of music I feel closer to them.

For me, music is art and I’m starting to compose by myself and my friend’s opinions are very positive.

My dream isn’t to be famous, but to play wherever I get the chance and to be respected by great artists. (Fabio, 17) From the observations that emerged from the replies, we put forward the hypothesis that an expressive music therapy project using mainly non-verbal mediation could represent an experience of facilitation of expression and communication also at a verbal level, of education in listening to themselves and others in a more elaborative way and of increasing of self-esteem and enhancing of personal qualities.

The model we referred to was that of interactive music therapy which is related to the free improvisation therapy in a humanist-existential psychological frame of reference. The project anticipated the involvement of one active music therapist and one in the role of supervisor.

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The subsequent stages of the project involved, over three years, 86 males from 15 to 18 years of age in group music therapy projects. The boys who were recommended for and referred to music therapy by the teacher class committee, and therefore with the agreement of all curriculum teachers, were representative of the most difficult situations in the whole school.

All of these adolescents showed strong relational difficulties and communication problems; often involved in aggressive incidents, most of them showed themselves to be intolerant of the teachers and by this stage indifferent and resigned to their very poor school results. For many, giving up school seemed certain at this point.

Some of them showed clearly deviant behaviour.

A smaller percentage of the youngsters, however, in almost a mirror-image, showed strong inhibition and withdrawal; also withdrawn in their posture, they almost couldnâ&#x20AC;&#x2122;t utter a word and were often isolated from the group when they werenâ&#x20AC;&#x2122;t being mocked without any chance of reacting.

We began the active music therapy sessions, carried out from March 2002 to May 2004 with groups of different young people in the periods and arrangements summarised in the following table:

Mar-May

Industrial

1 group / 10 boys

9 Mt sessions;

2002

Technical High School

Different classes

1 hour a week.

Age 15-17

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Nov 2002-

Industrial

5 groups / 8 boys each

9 Mt sessions;

May 2003

Technical High School

Different classes

1 hour a week.

Age 15-18 1 group / 20 boys

5 Mt sessions;

Same class

1 hour a week.

Age 15-16 Feb - May 2004

Professional High School

1 group / 16 boys Same class Age 15-17

Interview/Open question: “When I listen to music..”

6 Mt sessions; 1hour and 30 min every 2 weeks.

One further element that we considered to be important in organising the project was an individual introductory interview where the music therapist presented the project to each student and tried to gather useful data for the definition of his “musical profile”.

Where a class group had been referred the interview was carried out with the whole group.

The commitment was “free” with the possibility to withdraw from the experience at any time. The families were informed and gave their consent.

In total 99 people were contacted of which 86 agreed to and completed the project (8 did not attend regularly). This high percentage of participation in the project undoubtedly influenced the time at which the sessions were held: the young people actually met with the music therapist during school time (lesson time). In order to carry out the sessions during school hours the collaboration of the teachers proved to be essential, a factor which gave the students who participated the sense of an experience which was not unrelated to and detached from their educational itinerary in school.

Observations and remarks on the music therapy process:

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In the various group projects, the first sessions were generally characterised by a somewhat variable quality of verbal communication: very limited in the case of the more withdrawn and inhibited students, constantly present in the case of the group characterised by a more intense and “noisy” style in which there was a strong need to fill every silence with words or noises.

The participants responded positively to the music therapist’s first requests to present themselves using an instrument: almost everyone agreed to play, immediately approaching the instruments. The choices of instruments were somewhat varied: the large percussion instruments (tumba, congas, djambé, bongos…) were chosen by a higher percentage and were preferred by those who showed characteristics of aggressive behavioural intensity which was difficult to handle. These characteristics, already evident within the class, found expression in music through strong, imposing intensities that were sustained for long periods of time, especially during the first sessions. The request from these youngsters through music seemed to be for visibility and acknowledgement of their leadership.

This type made up a significant part of the percentage of the students who had been indicated by the teachers as being “difficult” to handle within the class.

A smaller percentage also showed an immediate approach to the instruments, but in a way that was characterised by lower sound intensity, the choice of smaller-sized instruments and greater variability in the choice of timbre. The gestural expressiveness of this second group in the production of sounds was very controlled and characterised by small movements. The instruments appeared to be used in a more defensive rather than expressive way; their improvisations seemed to more centred on themselves but at the same time they let key individual stylistic features filter through. It goes without saying that often these students were completely dominated by the high intensity of others and it was difficult, also for them, to listen to what they were playing.

In this second group of youngsters the choice of instrument was more varied over time, although a sort of identifying instrument in which they could recognise themselves did seem to emerge for each student. During one session Giacomo, a 16 year old boy who was extremely closed to relationships and had a passive attitude in class, was playing a small egg that he had repeatedly chosen and said: “I’m like this”.

During the first sessions the music therapist’s sensation was that she was able to represent for the group a sort of “scapegoat” upon which they could heap much of the frustration built up over the years, especially in school. She felt that she “per-

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sonified” the school institution and the difficulties experienced there every day: in one of the first sessions in one of the groups a boy turned up asking to listen to a song by Giorgio Gaber. Listening to this piece in the group, the singer’s voice, which explicitly asks adults not to “teach their own outlook on life” to their children but to give them the possibility to make choices and mistakes by themselves, made a strong impact on everybody.

On the whole, the group improvisations in the early sessions were characterised by a high level of sound intensity and by the quick attuning of the group to elements of rhythm and pulse that it was difficult to diverge from. These rhythmic elements were sought in the group’s shared repertoire using criteria of similarity and identification.

Another feature of the early sessions was the boys’ “background noise”. They had difficulty not filling moments of silence between one improvisation and another with words, laughs, mutual teasing and jokes, allowing their difficulty in maintaining the aspect of listening to what had been created and their need to fill these moments with various types of sound to show through.

During this phase, spaces for symbolic elaboration of the experience were few or none.

The role that the therapist felt she should cover in the first part of the sessions was more geared towards “guaranteeing” and safeguarding each person’s individuality: of the more vulnerable and less audible youngsters at a musical level by paying attention to the “pianissimi” and the nuances present but less evident, but also allowing the “noisier” participants to give a problematic but not destructive form to their intensity.

Though still without making too many proposals, in this phase the music therapist listened and supported the free expression through improvised music of the individual characteristics of each student. Slowly and gradually we assisted to a decrease in the expressive “urgency” that had been shown by the youngsters and a perceptible acceptance of new proposals from the therapist was observed.

These proposals were largely centred on techniques of turn taking and of the figurebackground, solo-tutti relationship. The very louds and very softs were gradually enriched with varying degrees in between.

In the central sessions of the various projects, the improvisations acquired referential aspects which were previously completely absent: more and more often the par-

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ticipants gave their improvisations titles both before and after playing them, on the one hand highlighting the capability to give musical shape to an experience and an emotion while on the other being able to identify and recognise these in the musical expression of a performance. (Noise>To Pour out; We are black> We are grey, Freedom>Happiness; Differences>Respect; We are fed up with school>Let’s go away).

The gap between one improvisation and another began to empty of background noise and, although with difficulty, some sensations and reworking of the experiences created together were able to emerge.

This shouldn’t lead you to think that the stylistic aspects, both typological and musical, of the youngsters had changed, but rather that, from this moment on, they found a different way of identifying with and encountering each other.

It was in this phase of the various projects that some of the youngsters shared the nature of their problems with the group and how these were difficult to live with in the school environment.

Identification of the boys between their poor results in school and their own selfesteem also emerged.

The therapist’s sensations in this phase were of being recognised more for her own stylistic and musical characteristics, losing the connotation of an “adult from the school”.

As the sessions progressed a change was observed in the style of listening to their own and their companions’ musical productions: the improvisations took on a more dialogic character with an increase in listening to musical proposals and responses and more reciprocal play was possible in the figure-background sequences. On a musical level, moreover, greater willingness was observed to takes turns in the role of leader and to acknowledge different styles of musical leadership. In the last few sessions, the quality of the verbalisation following the improvisations also confirmed the shift towards a more introjective and elaborative type of listening and participation.

In most of the groups, following the music therapist’s suggestion, the students kept the last session for proposing listening to pieces identified as representative either of recent individual experiences and/or of the experience they had had together.

Listening to these proposals, which were of various genres and styles but were mainly rock, was almost always characterised by an atmosphere of mutual listening

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and respect, even in cases of somewhat different tastes. The therapist also chose and proposed a piece for the group to listen to from the classic repertoire.

The end of each cycle of sessions was followed by a meeting of the music therapist with the teachers and, where possible, the parents.

One of the first comments to make was that this type of process was more evident in the groups made up of young people from different classes. In the music therapy groups formed by class groups, and also with a higher number of participants and a lower number of sessions, the work was less expressive and more sclerotic in terms of group dynamics. The roles of the youngsters within the class were better known and it was more difficult to break away from this in order to find new possible equilibriums.

Of the 70 youngsters who participated in the music therapy groups till 2003(the last 16 are now ending the school year) we have now a follow up about 50 of them.

Among these 50 boys, 7 left the school. Unfortunately we cannot compare this data with previous one we never had.

The next year to each group project, the music therapist asked some information about the boys to some of them teachers. In many occasions the teachers observed that generally they were more expressive and communicative and that they were more able to cope with frustrations, even those boys that were not successful at the end of the school year and decided, anyway, to continue.

Conclusions We would like to conclude our work with some reflections on the sense that we think an experience of music therapy can have for adolescents in various contexts.

The experiences carried out in clinical situations, presented on other occasions, and these latest experiences carried out in schools would appear to confirm that for many adolescents the maturation and enhancement of their means of relating to music can, more than other approaches, contribute to the restructuring and development of the relationship that the subject establishes with himself and with the world.

The specificity of the restructuring role that musical experience can perform with adolescents compared to other therapeutic approaches seems to lie in the constituent features of music itself which, as we have already said, is capable of offering

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Conclusions

many different things to a young person, different but simultaneously present. Perhaps even more important is the offer of freedom to listen to and acknowledge what in that moment is the “thing for me” without the music suffering from it.

It seems to us that, in his relationship with music, an adolescent can come into contact with the place where the simultaneousness of contradictory states can be encountered and lived in a less dramatic and paralysing way, but rather where he can allow the more mature parts of himself to evolve and the still insecure parts to wait, acknowledging the dignity and “mutual empathy” (“simpatia”) of both.

The way “how” this acknowledgement is carried out characterises what we define “style” and we consider the true testimony of the identity of the person in the here and now (Gaggero, 2003), a dimension of wholeness and integration, that dimension of “sense” that music can connect or reconnect with.

In this experience with the adolescents we saw that being able to be reached, without words, where they were, as much within a chaotic and overwhelming intensity as imprisoned by a repetitive and stereotyped rhythm without these experiences having to be put into categories of “right/wrong”, often proved to be the only possible starting point for exploring “variations” which up to that point were felt to be impossible or unacceptable.

We can think of several moments when the rhythm was accepted as an opportunity to reveal and recount an internal tempo perceived either as “too” slow and feeble or “too” fast, intense and unsettling. That which in life can be painfully experienced as “too much” or “too little”, in music can take shape and, even better, define a personal style. Therefore we have music that is organised around a slow and heavy pace, alternated by long silences, and which can give voice to the nature of that condition.

Just like the strong intensity, which on a behavioural level often erupts into painful actions, often took shape in loud, percussive improvisations which only with great difficulty managed to conquer a moment’s silence but which, in this state, were able to offer a shareable and somewhat reassuring sound representation.

We have observed how important this offer is in a clinical situation with psychopathological problems where, in the most successful cases, the experience of restructuring the relationship with music encourages and corresponds to a structural reorganisation of disharmonic elements of the personality; in the schools described in this work the music therapy experience showed its “preventive” worth as regards risk factors in adolescence.

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A constant that we observed in all areas of work with adolescents is that, through a suitable relationship with music, the body, the emotions and the thoughts can start to communicate with each other again via a channel which includes them all but which can also save a space for greater emphasis on one of them without excluding the others.

It is in this moment that we often witness a re-orientation of desire for the world, for a story that can be written or, if interrupted, can gradually start to develop again.

The language that can allows an adolescent to talk about herself/himself is no longer the language of childhood; it is made by a new tastes, new words, new style that she/he doesn’t yet know.

This new style cannot be “taught” …. we can accompany youngsters, motivating them to discover and listen to it and to clothe it in “their” creative will.

BIBLIOGRAPHY AA. VV., (1989), L’ascolto che guarisce, Cittadella editrice, Assisi.

Ansaldi G., (1993), La “lingua degli angeli”. Introduzione all’ascolto della musica; Guerini Studio, Milano.

Ballerini A., Callieri B. (a cura di ), (1996), Breviario di psicopatologia, Feltrinelli, Milano.

Borgna E., (1999), Noi siamo un colloquio, Feltrinelli, Milano 1999.

Bruscia K., (1987), Improvisational models of music therapy, C.C.Thomas Publishers, Springfield.

Bruscia K., (1998), Dynamics of Music Psychotherapy, Barcelona Publishers.

Bunt L., (1994), Music Therapy. An Art Beyond Words, Routledge, London.

Bunt L., Gaggero G., Zanchi B., (2001), Interpretazione Musicale e Relazione Terapeutica, Atti della V Conferenza Europea di Musicoterapia, (CD- ROM) Napoli.

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BIBLIOGRAPHY

Cordoni L., (2002), Adolescents and Music Therapy in Italian Schools, Proceeding of the 10th World Congress of Music Therapy, Oxford,2002 Ferrari A., (1994), Adolescenza, La seconda sfida, Borla, Roma.

Frontori L., (1992), Adolescenza e oggetti, Cortina, Milano.

Gaita D., (1991), Il pensiero del cuore: musica, simbolo, inconscio, Bompiani, Milano.

Gaggero G., (2003), Esperienza musicale e musicoterapia.,Mimesis, Milano.

IARD., (1996), I giovani e la musica(Echi sonori dalla Quarta Indagine IARD), Milano.

Imberty M., (1988), Suoni, Emozioni, Significati, CLUEB, Bologna.

Manarolo G., (2004), Musica e adolescenza, Musica e Terapia n. 9, Cosmopolis, Torino Mariotti, M., Frison R., (2000), Relazioni terapeutiche e adolescenti multiproblematici – L’esperienza de la Rotonda -, Franco Angeli, Milano.

Meltzer D., (1981), Quaderni di Psicoterapia infantile n.1, Borla, Bologna Novelletto A., Maltese A. (a cura di), Adolescenza e psicoanalisi, Quaderni di psicoterapia infantile n˚43, Borla, Roma.

Palmonari A., (1997), Psicologia dell’adolescenza, Il Mulino, Bologna.

Postacchini P.L., Ricciotti A., Borghesi M., (1997), Lineamenti di Musicoterapia, Carrocci, Roma.

Postacchini P.L., (2001), Musicoterapia e Tossicodipendenza, Musica e Terapia n.

4 , Cosmopolis, Torino Ricciotti A., (2000), Musica e adolescenza, In Mariotti, M., Frison R., Relazioni terapeutiche e adolescenti multiproblematici – L’esperienza de la Rotonda -, Franco Angeli, Milano

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Ricciotti A., (2004), Forme musicali e vita mentale in adolescenza, Musica e Terapia n. 9, Cosmopolis, Torino.

Smeijsters H., (1995), The Functions of Music in Music Therapy, in Wigram, Saperston West: Art and Science of Music Therapy: A Handbook, Harwood Publishers, Amsterdam.

Tagg P., (1982), Analysing Popular Music: Theory, Method and Practise, in Popular Music n. 2, 37 67.

Violi R., Draisci G., (2000), In Mariotti, M., Frison R., Relazioni terapeutiche e adolescenti multiproblematici – L’esperienza de la Rotonda -, Franco Angeli, Milano.

Zanchi B., Camerini M., (1999), Forme musicali in divenire .L’intervento educativo e la musicoterapia in una semiresidenza psichiatrica per adolescenti, Proceedings of the International Conference “Comportamento e Disturbi Psicopatologici in Età Evolutiva”, AUSL Città di Bologna.

Zanchi B., Corraini M., (2001), Le Terapie espressive in Età Evolutiva, Poster published at the International Conference: “Le Terapie in Psichiatria dell’Età Evolutiva”, Azienda USL Bologna.

Zanchi B.,(2002) “Style and Identity. “Being in the world” as a musical form. A clinical story” in Proceedings of the 10th World Congress of Music Therapy, Oxford,2002; available at hpp: // musictherapyworld.net BARBARA ZANCHI,

Musictherapist, musician and psychologist, she is the President of MusicSpace Italy. She is the Co-ordinator for the University of Bristol of the Italian Course of the Post-Graduate Diploma in Music Therapy. As a clinician she works in a Psychiatric Service for Adolescents and in some private institutions for both children and adults.

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June 16-20, 2004 University of Jyväskylä , Finland

Appendix - List of figures Mean (M%) of independent responses for Phillip and Ben during the morning greeting routine in each condition of the study. 574 Mean (M%) of Andy’s independent steps during the clean up, hand washing, and toileting procedure in each condition of the study. 578 Mean (M%) of positive peer interactions for each target child by each condition of the playground study. 581 The model 617 621 Intensity Profiles “Significant moment” Improvisation I. 639 “Significant moment” # 3. Improvisation I. 640 Intensity profiles “Significant Moments”. Improvisation II. 643 (Video 1 - Piet) 660 (Video 2 - Gesa) 661 (Video 3 - Bathing ) 665 (Video 4 - Ben1) 666 (Video 5 - Claire1) 667 (Video 6 - Ben2) 668 (Video 7 - Claire2) 669 a

(Video 8 - Ben Lucca 1) 670 (Video 9 - Ben Lucca 2) 671 (Video 10 - Ben Lucca 3) 672 (Video 11 - Anna 1) 674 (Video 12 - Anna 2) 675 (Video 13 - Anna 3) 676 (Video 14 - Anna 4) 677 (Video15 - Anna 5) 678 Process of initial assessment in music therapy 706 Assessment sessions 710 The final stage of initial assessment 716 778 780 The fundamental properties of touch sensation 828 Receptor types and characteristics of afferent fibers from the glabrous skin of the human hand. RA=rapidly adapting; SA=slowly adapting; PC=Pacinian afferent. The ramp in the adaptation column indicates skin indentation. From Kaas, J. H. (1990). Somatosensory System. In G. Paxinos (Ed.). The Human Nervous System (p. 815). b

San Diego: Academic Press 829 The therapeutic monochord of the Tone-Transfer-Therapyâ&#x20AC;&#x153; picked to pieces (Patent-Nr.P4431 904.5) 833 The therapeutic Monochord in different shapes 834 Two new models of the therapeutic monochord, left from Dosch/ Munich, right from Deutz/Berlin 835 Extrinsic muscles of the larynx. Like the rays of a star the muscles of the larynx point radially to all directions of the bodyFrom Cramer (1998). Das Buch von der Stimme. Ihre formende und heilende Kraft verstehen und erfahren. ZĂźrich, Walter, p. 38 837 856 858 859 861 867 Pre- and post-test patient outcomes measurement scale. 890 Music therapy outcomes. 893 Drum Circle (Participants of a workshop at the EMTC conference in Finland) 909 Drum Circle 2 (Participants of a workshop at the EMTC conference c

in Finland) 911 Working with lyrics (Participants of a workshop at the EMTC conference in Finland) 916 A schematic representation of the method for obtaining a system for automated analysis of improvisations. 926 Hierarchy of the analysis tools used 928 Temporal evolution of the musical variables (on the left) and their respective imitation diagrams (on the right). 929 Musical density depicted as a MTTB graph 931 Utilizing musical density in dividing improvisation into parts 932 Piano roll representation of the part with high density. Blue = lower stave, Red = higher stave. 932 Velocity graph of the part with high density 933 945 946 947 949 951 953 d

955 955 956 957 958 959 Subj. 2 (Angelika) 959 960 961 962 994 995 996 997 998 1002 1003 e

1003 1006 1023 1028 1033 1056 1057 1057 1058 1058 1059 1059 1060 1060 1061 1061 1062 f

1062 1063 1063 1064 1064 1065 1065 1066 1066 1067 1067 1068 1068 1069 1069 1070 1196 g

1197 The Operating Theatre The Intensive Care Therapy Ward 1208 The Operating Theatre The Intensive Care Therapy Ward 1208 1210 The setting ready to start the sitting 1213 Before and after a Group GIM session 1260 Before and after a Group GIM session 1261 Music Inside 1269 “By music experience I was curious to explore inside and outside world. Now I am aware that there is earth, sky, and below, as in myself, too” 1271 Liete Dissonanze 2002: Public Presentation Of The Songs 1282 LIETE DISSONANZE 2004: ONE OF THE PUBLIC PRESENTATIONS OF THE CD 1283 LIETE DISSONANZE 2004: ONE OF THE PUBLIC PRESENTATIONS OF THE CD 1284 The Modulation Model by Ogden & Minton (2000) 1300 A client listening to music in the physioacoustic chair. 1305 1330 h

1331 1332 . 1333 1350 1356 1359 1367 1368 Countries included on the European Higher Education Area (colorcoded geographical areas indicates order of participation) 1381 Information on the Spanish National Higher Education System 1386 Score of the new unfamiliar song, 'Present My Love' 1419 Mean subjective tempo recorded in music therapy sessions 1421 LLearning process of the new song, ‘Present my love’ 1424 Episode “becoming playful” 1431 Flexible design 1434 1435 i

Self - acceptance (SESA) 1436 Subscale anxiety (HADS-A) 1437 Episode “thinking about music” 1439 Basis parameters for contact - 1 1440 Basis parameters for contact - 2 1441 Basis parameters for contact - 2 1442 1444 Episode “moving instrument”. 1445 Episode “singing” 1446 Episode “playing and singing” 1447 Episode “becoming playful” 1448 Episode “Swing in my brain” 1449 Basler Scale: four sub-groups 1463 Triangular dynamic 1464 Emotion model (Bernd Tischer 1993) version I 1466 Type 3 1472 Kolb’s learning cycle 1590 j

single and double loop learning (Argyris, C, and Schรถn, D 1978) 1593 Music Therapy Research, Edition 2 1610 Results of Visual Analogue Scale, Cardiac Demonstration Project 1622 (1st recording+slide) 1629 (2nd slide). 1630 (3rd slide). 1631 1632 (5th slide) 1633 (6th slide). 1634 (7th slide). 1635 (8th slide) 1636 (9th slide) 1637 Animals in Exile 1643 typical tales features 1645

k

Appendix - List of tables

Continuum of six models of music therapy service delivery in inclusive childcare settings. 567 4 steps in the music therapy session 606 658 664 672 Seriousness of damage to cognitive functions in schizophrenic patients 812 Tests results 818 Tests results 2 818 Results using the Wilcoxon test 819 Differences between the VAT and the VAM 831 The differences between the instruments of the VAM and the therapeutic monochord of the Tone-Transfer-Therapy 836 Main differences between individual speaking fundamental frequency and individual basic voice-tone 839 Abbriviations 935 Results of regression analysis for ACTIVITY. Using the simultaneous method of variable entry, a significant model emerged [F(15, 2384) = 196.462, p<.001; adjusted R square = .553]. Significant l

variables are shown below. 936 Results of regression analysis for VALENCE. Using the simultaneous method of variable entry, a significant model emerged [F(15, 2384) = 24.403, p<.001; adjusted R square = .128]. Significant variables are shown below. 937 Motor function 1120 Sensory perception 1123 Social competence 1126 Emotion 1129 1131 Cognition 1133 References 1164 An example: Themes under a category of â&#x20AC;&#x153;interpersonal relationshipsâ&#x20AC;? 1184 The categories and their main points 1188 Contact 1257 Stabilization 1257 Problem Solving 1258 Re-construction 1259 m

Leonardo – Spastic tetraparalysis – 20 years old 1262 Manola – Down Syndrome – a 40 years old woman 1263 Felix – development impairment – a teenager boy 1264 Rodrigo – Schizophrenic pathology – a 39 years old man 1266 Loredana – paranoid schizophrenia – a 35 years old woman 1267 Summary of the action lines introduced in the construction of the EHEA 1379 Spanish grading system according ECTS grading scale 1387 Information included in the Diploma Supplement 1388 Music Therapy Training Courses in Spain (May, 2004) 1393 MATRIX FOR DATA COLLECTION 1394 Optional subjects offered at University undergraduate studies in Spain during academic year 2003-2004 1401 Severe group and non-severe group (2001) 1417 The learning period of each stage 1426 Research design 1460 Evaluation sheet 1465 Quadrantenmodell 1468 n

Methods used 1475 Music Therapy at the Department of Rehabilitation 1515 Historical background 1518 Psychodynamic Short Term Therapy Concepts 1519 Strupp & Binder: The Psychodynamic Short Term Therapy 1520 Focal Music Therapy 1521 Answers to research question 1649 L.â&#x20AC;&#x2122;s Categories/Themes based on the analysis of the responses/dialogue that occurred during/after 7 identified significant music therapy experiences 1677 O.â&#x20AC;&#x2122;s Categories/Themes based on the analysis of the responses/dialogue that occurred during/after 3 identified significant music therapy experiences 1680

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